Failure to Investigate Injury of Unknown Origin and Follow Abuse/Neglect Reporting Policy
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin and to respond in accordance with its abuse/neglect and injury-of-unknown-source policies. The facility’s written policy, dated 12/2025, requires that all allegations of abuse, neglect, mistreatment, injuries of unknown source, and resident rights violations be promptly and thoroughly investigated, with immediate measures taken to ensure resident safety, timely reporting to the administrator and appropriate agencies, and completion of a Caregiver Misconduct Incident Report within five working days. The policy also defines injuries of unknown origin as those where the source is not observed or cannot be explained by the resident and is suspicious due to extent, location, or pattern of injuries, and outlines specific investigative steps such as interviewing staff and residents and reviewing prior shifts. The resident involved was admitted with multiple significant medical conditions, including cerebrovascular disease, severe unspecified dementia with a BIMS score of 00, anxiety, and bilateral hip osteoarthritis. Progress notes show that on 12/19/25, staff documented a change in the resident’s left pinky finger, initially noting skin problems and later describing a large, red, warm hematoma on the lateral aspect of the finger. The resident’s POA and on-call physician were notified, and the resident was transferred to the emergency department that evening. Hospital records from that visit document that the resident presented with hand pain and a swollen left pinky with pus drainage, with the history noting it was unclear whether there had been an associated injury. Diagnostic imaging at the hospital identified a possible closed nondisplaced fracture of the distal phalanx of the left little finger, along with an abscess. During a subsequent surveyor interview, an LPN reported that the finger had been broken about a month earlier, that osteomyelitis had been found, and that the resident’s left hand was contracted, requiring staff to pull the fingers up to apply palm protectors, but the LPN was not aware how the fracture occurred. When the surveyor requested an incident report and weekly wound assessments related to the injury, the DON stated there was no incident report and no weekly wound assessment documentation. In a separate interview, the administrator acknowledged that an injury of unknown source should be reported to the state and that the resident’s finger fracture should have been investigated to determine its cause, confirming that the required investigation and reporting processes were not carried out.
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.