Failure to Thoroughly Investigate Injury of Unknown Origin and Inconsistent Documentation of Contractures
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an injury of unknown origin for one resident with severe cognitive impairment and extensive physical limitations. The resident had vascular dementia with anxiety, Alzheimer’s disease, fibromyalgia, weakness, and multiple lower extremity contractures, and was dependent for all ADLs with transfers requiring a Hoyer lift and two-person assist. The care plan did not specify sling size for Hoyer transfers. The most recent MDS indicated the resident was rarely/never understood and had upper and lower extremity ROM impairments, while multiple weekly nursing skin/condition assessments documented no contractures present. Therapy records, however, showed the resident had significant BUE contracture and ROM issues that affected bathing and dressing, with documented spasticity and tone differences. On the date of the incident, nursing staff were notified of bruising on the resident’s left arm and left breast, along with pallor and poor oral intake. The RN assessed what he described as a small bruise on the back of the arm, reported it to the DON, and was instructed to monitor for worsening, but he was unsure if he documented the size and exact location. The CNA on duty that morning reported she did not look at the resident’s upper body, did not observe bruising, and only reported that the resident appeared different and pale. There were no reports of falls or equipment malfunction, and staff interviews did not identify a clear cause of injury. Subsequent evaluation in the ER identified an anterior left shoulder dislocation with associated ecchymosis, and the ER physician expressed concern for possible abuse or neglect given the resident’s non-ambulatory status and lack of reported falls. During the facility’s internal review, the DON stated that the facility could not determine how the resident sustained the dislocated shoulder and bruising and acknowledged there was no documented explanation for the injury. The DON reported that the facility ultimately assumed the cause was improper upper body dressing technique related to contractures, based on the ER note suggesting this as a possibility and the absence of reported falls or equipment misuse. However, the DON was unable to produce nursing documentation supporting the presence of upper extremity contractures prior to the incident and was unaware that nursing assessments repeatedly documented no contractures. A disciplinary form for a CNA who admitted to transferring the resident alone with a Hoyer lift, despite a two-person requirement, was included in the investigation file, but the form did not identify the resident or provide details of the event. The police report documented that the DON told law enforcement the facility was not able to figure out how the resident obtained the dislocation and bruising, and no further information from external agencies was available in the facility’s investigation file.
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