Failure to Thoroughly Investigate Alleged Lip Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of an injury of unknown origin to a resident’s lip. The resident had a history of stroke with right-sided hemiparesis and aphasia and was documented on the MDS with a BIMS score of 0/15, indicating they were rarely understood or unable to complete the mental status interview. A family member contacted the social worker to report concerns about the resident’s care over a weekend and specifically that the resident had something on their lip and was upset about it. During this call, the Nursing Home Administrator, who is also the abuse coordinator, became aware of the concern. Subsequently, the social worker documented a wellness visit with the resident, noting that when asked about how they were doing following the incident, the resident repeatedly pointed to their mouth and nodded yes that they wanted to see someone regarding the incident. However, there was no documented skin assessment or oral assessment in the electronic health record related to the lip injury, and no additional progress notes describing the condition of the resident’s mouth, lips, or oral cavity. The social worker stated that they did not assess the inside of the resident’s mouth, indicating that such an assessment would be for nursing to perform. The nurse unit manager LPN reported that they had looked at the resident’s mouth and observed a small, dried crack on the bottom lip that appeared chapped, but confirmed there was no progress note or documentation of this assessment and that no interviews or investigation were conducted by them. The DON later stated that an investigation had been completed and kept in a paper file, concluding that the resident bit down on a toothbrush during oral care, causing a small crack or split on the bottom lip that looked like chapped lips rather than an injury. The DON reported interviewing only one CNA, an agency staff member, whose unsigned witness statement described the lip slit occurring during oral care; no other staff or resident interviews, additional assessments, or documentation were completed. This limited and poorly documented response did not meet the facility’s own abuse policy requirements for a timely, thorough, and objective investigation of alleged injuries of unknown source, including comprehensive interviews, observations, record review, and complete documentation.
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