Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a severely impaired cognitive status with a BIMS score of 7/15. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing injuries, monitoring vital signs, and notifying the physician. Another care plan problem identified impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one date, a PTA documented on a Witness Written Summary that during a therapy session the resident was noted to have increased edema on the right forearm, and the resident was unable to explain what happened or quantify pain due to cognition; nursing was notified. Later that morning, an LPN documented on a Witness Written Summary that the resident had a hematoma to the right forearm, was unable to recall what happened, showed signs of pain, and was given pain medication per physician order, and the NP was made aware. The NP’s progress note the following day described right arm swelling in the context of multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. In interviews, the Administrator and DON stated they determine whether incidents need to be reported to the state, and the DON confirmed this incident was not reported or investigated. This was inconsistent with the facility’s abuse/neglect policy, which requires all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and investigated, with reporting to appropriate regulatory agencies and/or law enforcement.
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