Failure to Investigate Injuries of Unknown Source for Two Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to initiate required investigations into injuries of unknown source for two dependent residents. For the first resident, who had mild cognitive impairment, significant obesity, and required substantial/maximal assistance for mobility and was totally dependent for toilet transfers, staff documented acute onset of severe left-sided chest pain during repositioning. A CNA reported to an RN that the resident screamed in pain when rolled for incontinence care, and the resident rated the pain 8/10 and described it as sharp. The resident was sent to the emergency department, where imaging showed bilateral anterior chest wall contusions. The ED documentation noted the pain began after an aide rolled the resident several days earlier, and that the resident required almost 100% assistance to move and had pain reproducible with palpation and movement of the left arm. Subsequent nursing notes for this resident documented that the resident’s representative was upset that staff had been transferring the resident without using the stand-up lift and believed this contributed to the chest pain. A physical therapist was unable to work with the resident due to pain and planned to evaluate safe transfers later, and staff were instructed to use the stand-up lift until that time. Additional notes showed the resident continued to complain of chest wall pain, used PRN hydrocodone, and expressed concerns about care and staff attitudes, specifically stating not wanting a particular CNA in the room and reporting that the resident’s daughter shared this wish. In an interview, the resident reported that a CNA had grabbed the resident around the chest during a transfer and indicated ongoing soreness in the left upper chest, though the resident declined to provide further details. An RN later stated the resident had told her that a CNA had transferred the resident without the sit-to-stand lift and that she had emailed the DON and another RN about this allegation. For the second resident, who had severe cognitive impairment and required substantial/maximal assistance or total dependence for bed mobility and all transfers, nursing documentation showed that bruising was observed around the anus, described as red/purple in color, and later noted as bruising that was going away. There was no documentation that the cause of this bruising was identified. Facility documentation showed no evidence that either resident’s injuries of unknown source were investigated. The chief compliance officer reported that no occurrence report related to the first resident had been received, and another RN stated the facility did not track injuries of unknown origin. The DON confirmed that the facility’s Abuse Prohibition policy, which requires immediate investigation of alleged violations involving mistreatment, neglect, abuse, including injuries of unknown source, had not been followed and that occurrence reports had not been filed for these injuries.
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.