Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prohibition policy by not conducting a thorough investigation into an injury of unknown origin for one resident. The resident was bedbound for the past 3–4 years, required extensive assistance with turning in bed, was dependent on staff for all transfers via mechanical lift, and only got out of bed on dialysis days. On the day of the incident, the RN documented that the resident’s right arm appeared normal at the beginning of the shift and at medication pass, but later that day the restorative aide observed the resident grimacing, not eating well, and noted swelling and deformity of the right wrist with the resident unable to move fingers. The resident was subsequently sent to the hospital. At the hospital, EMS reported that the resident had a fall the previous day and that imaging showed distal radius and ulna fractures. The resident stated she remembered falling the previous day. The emergency room exam documented a small hematoma on the right lateral head and swelling with obvious deformity of the right wrist. X‑rays showed mildly comminuted fractures of the distal radius and ulna with displacement and soft tissue swelling. The orthopedic surgeon noted an unclear, unwitnessed mechanism of injury given the resident’s bedbound status and also noted the head injury and wrist deformity. There was no documentation in the hospital record that the right arm injury was due to a pathological fracture or that the resident had osteoporosis in the right arm. The facility’s internal investigation was limited to statements from the RN, restorative aide, and one CNA, and did not include statements from all staff who worked on the resident’s unit in the days preceding the incident. The investigation concluded that the right arm injury was a pathological fracture, despite the absence of supporting hospital documentation and the presence of a head hematoma in the hospital record. The administrator stated the resident injured the arm on the side rail, and the DON reported that a roommate said the resident hit her arm on the side rail while rolling up the top sheet. The DON also stated she believed the fracture was pathological based on the resident’s comorbidities and referenced a phone call to the hospital, but could not identify whom she spoke with. The facility’s abuse prevention and reporting policy defines injuries of unknown source and requires that final investigation reports be based on known facts; however, the investigation did not fully explore or reconcile the conflicting accounts of a fall, the head hematoma, and the mechanism of injury, resulting in a failure to conduct a thorough investigation of an injury of unknown origin.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.