Failure to Conduct Thorough and Credible Abuse Investigation After Severe Eye Injury
Penalty
Summary
The facility failed to conduct a thorough and credible abuse investigation for one resident who sustained a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. The resident, who had Mild Alzheimer's and was taking Eliquis (Apixaban), initially alleged that a CNA hit him, an allegation documented by the first clinician on the scene, an agency RN. This RN also observed the CNA in an agitated and angry state over a broken necklace and reported these observations, including the resident’s statement that the CNA hit him and that a staff member had reported the incident as an assault via a 911 call, to the Administrator and management. However, these critical observations and the documented allegation of assault were omitted from the facility’s formal report to law enforcement. The facility concluded that the injury was accidental, suggesting the resident struck his own eye, and did not consider or document the possibility that the necklace chain or pendant could have been the blunt object causing the injury. There was no evidence that the facility consulted a medical professional to assess whether a swinging pendant or a self-inflicted blow by an elderly resident with Mild Alzheimer's could generate sufficient force to cause the documented orbital fracture and globe rupture, or to reconcile how a minor accident could result in severe hemorrhaging requiring emergent surgery in a resident on Eliquis. Additionally, the Administrator reported to police that the resident recanted the allegation, but facility records did not show that the resident’s cognitive impairment or potential suggestibility after traumatic injury were considered, nor that a neutral advocate or social worker was present during the recantation. These omissions and failures in the investigative process resulted in an incomplete and medically implausible narrative being provided to law enforcement and demonstrated that the facility lacked a thorough implementation of an abuse investigation system required by Federal regulations.
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