Failure to Thoroughly Investigate Resident Head Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for Resident #47, who had dementia with agitation, cognitive communication deficit, and Parkinson's disease with dyskinesia. The resident had moderate cognitive impairment and required extensive assistance, including two-person assist with a mechanical lift for all transfers and dependence for most ADLs. On the morning of 2/18/26, staff observed an unwitnessed hematoma on the left side of the resident’s forehead while the resident was seated in a wheelchair at the nurse’s station. No one had witnessed how the injury occurred, and the two NA statements were inconclusive, only assuming the resident had hit his/her head on the bed’s headboard earlier in the morning due to dyskinesia. The ADNS reported that, after conferring with the Regional Clinical Director (RN #3) and indicating the cause was believed to be related to dyskinesia, it was determined the injury did not need to be reported to the State Agency as an injury of unknown origin within the 24-hour reporting window. The ADNS acknowledged not following the facility’s abuse policy requirement to conduct a thorough investigation, including going back 72 hours and interviewing all staff with access to the resident; instead, only the two NAs from the prior shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. RN #3 stated she believed a complete and thorough investigation had been done and that the cause was known, and that she would have had the injury reported as an injury of unknown origin had she known the investigation was incomplete. The facility’s abuse policy required a thorough investigation of alleged abuse or neglect by the Administrator and/or DON to determine if conduct violated standards of care, which was not carried out in this case.
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