F0609

D

Failure to Investigate Injury of Unknown Origin Involving Toenail Avulsion

San Pablo, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow the facility’s policy and procedure for investigating injuries of unknown origin when a resident was found with a complete avulsion of the right great toenail and the source of the injury was unknown. The resident’s MDS showed mild cognitive impairment with a BIMS score of 11, difficulty recalling the day of the week, and some difficulty communicating, including aphasia noted at the time of the injury, which prevented the resident from describing what happened. A CNA discovered the resident’s right great toenail was completely off, with the nail bed dry and red, and reported this to an LVN. The LVN asked other nurses about the cause, but no one knew how the toenail came off. The COC note documented that the resident often dangled her feet outside the bed and sometimes hit hard parts of the bed and nearby table, causing skin and nail damage.

Despite the unexplained nature of the injury and the resident’s inability to explain the cause, the facility did not initiate or conduct a thorough investigation as required by its policy titled “Injury of Unknown Origin-Investigation.” The LVN stated he assumed the toenail avulsion may have occurred because the resident dangled her feet and hit hard surfaces, but this was not confirmed. The DON acknowledged that the facility did not investigate the source of the toenail injury and that the IDT did not review the injury. The facility’s policy defined an injury of unknown source as one where the source was not observed or could not be explained by the resident and was suspicious due to extent, location, number, or incidence over time, yet no formal investigation or IDT review was completed for this resident’s unexplained toenail avulsion.