Failure to Thoroughly Investigate Resident Toe Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an injury of unknown origin sustained by Resident R1. Facility policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property required the investigator to interview the resident, the accused, and all witnesses, obtain statements from each, document evidence of the investigation, analyze the evidence, determine whether the suspicion was substantiated or unsubstantiated, review and revise the resident’s plan of care as appropriate, consider policy or procedure modifications, and complete staff training if indicated. The Nursing Home Administrator later confirmed being unable to locate documentation of interviews or investigation notes related to the resident’s injuries, indicating that the required investigative steps and documentation were not completed as outlined in the policy. Resident R1 had an original admission date of 2/11/25 and a readmission date of 11/11/25, with diagnoses including dependence on renal dialysis, open wounds of the right foot, stage three kidney disease, and gout. Interdepartmental progress notes documented that the resident returned from dialysis in a wheelchair and, approximately 1.5 hours later, staff observed a large amount of blood on the floor and on the resident’s left foot, with a blood clot, blood-soaked sock, and heavy bleeding from abrasions on four toes. The great toe had an open area with tissue missing, the fourth toe was missing the toenail with a bleeding nail bed, and the second and third toes were also bleeding; staff were initially unable to stop the bleeding and applied a pressure dressing. Later that evening, removal of the pressure dressing resulted in renewed bleeding that required cleansing and rewrapping. An email between the NHA and the contracted transport company showed the driver reported being unaware of any injuries to the resident’s toes, but no further investigative documentation was found in the record.
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