Failure to Investigate Discrepancy in Resident Injury Reports
Penalty
Summary
The facility failed to thoroughly investigate a potential allegation of abuse involving one resident who was found between the wall and the bed with injuries including a swollen right eye, facial swelling, and abrasions on the right shoulder and arm. The resident, who had significant medical conditions such as anoxic brain damage, epilepsy, and hemiplegia, was dependent on staff for care, transfers, and mobility. Staff interviews revealed inconsistent accounts regarding the presence and extent of the resident's injuries. One LPN reported finding the resident without injuries or bleeding and only cleaned sputum from the face, while a CNA described the resident as having a swollen, bloodied face and observed bloody washcloths nearby. The LPN did not document the incident in the medical record, and the discrepancy between staff statements was not investigated further by facility administration. The facility's administration was notified of the incident and initiated an investigation, but failed to address or reconcile the conflicting staff statements regarding the resident's injuries. The Nursing Home Administrator confirmed that there was no follow-up to investigate the discrepancy between the LPN and CNA accounts. As a result, the facility did not ensure a thorough investigation of a potential abuse allegation, as required, and did not document or clarify the circumstances surrounding the resident's injuries.