F0610

D

Failure to Assess and Investigate Resident’s Unexplained Eye Injury

Plainfield, Indiana Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate and clinically assess an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had diagnoses including Alzheimer’s disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, was care planned as a high fall risk and noted to wander and enter other residents’ rooms. On one day, the resident’s wife found him on the memory care unit with a swollen, darkly bruised left eye and reported that staff told her they did not know what had happened and had no plans for diagnostic tests such as an X-ray. She expressed worry that staff were dismissive of his injury. Observation by surveyors later showed the resident seated in a common area with a visibly swollen and discolored left eye, while he appeared calm and engaged in conversation.

Record review showed that a progress note documented the resident’s left eye as puffed and dark in color, with a plan to continue monitoring, but there was no documented assessment of vital signs, neurological status, or the left orbital area when the injury was discovered. A skilled evaluation note both before and after the injury documentation stated there were no changes in skin integrity. The clinical record lacked documentation of notification to the physician, appropriate facility personnel, or the resident’s spouse regarding the injury. The DON reported he was not informed of the injury until several days later and did not know who first discovered it. Although a risk management assessment was entered days after the injury, no interviews or assessments were completed at that time, and the incident was not promptly reported or thoroughly investigated as required by the facility’s Incident/Accident Reporting policy for unexplained injuries.