Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident had diagnoses including hemiplegia, hemiparesis, dementia, and a left above-knee amputation, and was dependent for hygiene, bathing, dressing, and position changes. A Significant Change MDS showed a BIMS score of 3, indicating severely impaired cognition. On a specified date, the resident complained of pain to the right lower extremity, and x‑rays of the right knee, tibia, and fibula demonstrated traumatic fractures of the proximal tibial and fibular diaphyses and tibial shaft. The facility completed a Critical Incident Report and substantiated an injury of unknown origin based on its policy criteria that the source of the injury was not observed, could not be explained by the resident, and was suspicious due to the extent and location of the injury. Despite policy requirements that the administrator thoroughly investigate all alleged violations and injuries of unknown origin, the investigation was incomplete. Nursing staff who rendered care during the 48 hours prior to discovery of the injury were to provide statements, but a CNA who provided care to the resident from 3:00 p.m. to 11:00 p.m. on the two days before the injury was identified was not interviewed or asked for a statement, even though she confirmed she had provided care during that period. Additionally, the administrator had access to 72 hours of facility video surveillance footage prior to discovery of the injury but reviewed only the previous 24 hours and acknowledged not reviewing the full 72-hour period prior to the injury, despite stating she should have done so.
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