F0610

D

Failure to Thoroughly Investigate Injuries of Unknown Origin for Two Residents

Haverstraw, New York Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate injuries of unknown origin for two residents, contrary to its own Accident–Incidents policy. The policy, last reviewed on 06/01/2024, requires that the Incident/Accident Statement Form list nursing staff caring for the resident at the time of the incident and one shift prior, identify any witnesses by name with completed statements, and that the Incident/Accident Report Form include all required information, staff identification, statements, and a complete investigation with a conclusion. For one resident with anemia, dementia, and hypothyroidism who had severely impaired cognition and required supervision with transfers and ambulation, a forehead hematoma was discovered on 12/10/2025 and reported to the Department of Health as an injury of unknown origin. The facility’s documentation did not include staff statements from those who provided care on prior shifts, nor did it contain a detailed description of the care provided before the injury was identified.

The roommate of this resident stated that no staff member interviewed them about the incident, and they were not asked to provide a written or verbal statement, despite being present in the room during the timeframe when the resident was last observed prior to being found with the hematoma. The facility’s investigation file did not contain a statement from the roommate and did not document whether abuse, neglect, or mistreatment was considered or ruled out. The Administrator reported that he did not initiate or complete the investigation, that the prior DON was responsible, and that he did not review the investigation or know whether it was complete. The current DON stated that the hematoma was determined to be an injury of unknown origin and that the investigation consisted only of statements from staff working the shift when the hematoma was identified, with no statements obtained from staff on prior shifts and no additional documentation beyond what was submitted to the Department of Health.

For another resident with anemia, dementia, and peripheral vascular disease, who had moderately impaired cognition, required supervision with bed mobility, was dependent for toileting and showering, and required substantial to maximal assistance with transfers, an acute non-displaced right tibial plateau fracture was identified by STAT X-ray after the resident complained of pain and guarded the body during turning and positioning. The facility’s investigation report documented that no incident was witnessed, but the Accident/Incident Statement Forms completed by one CNA lacked required identifying information, dates, shift or time of assignment, and did not describe the type of care provided, including how the resident was transferred or assisted with ADLs at the time of the occurrence. Another CNA’s statement form inconsistently indicated that they were not assigned and did not provide care, while elsewhere noting they were the assigned aide for an appointment, and the form did not describe the care provided, the role during the outside appointment, or how the resident was prepared or transferred.

Interviews with CNAs revealed conflicting accounts of whether a Hoyer lift or a stand-and-pivot transfer was used to move the resident into the wheelchair for an outside medical appointment and back into bed afterward. One CNA initially reported that a Hoyer lift was used to transfer the resident into the wheelchair, then later stated this was a mistake and clarified that the Hoyer lift was used only upon return from the appointment to transfer the resident back to bed because the resident was tired, while also stating that the resident was not a Hoyer lift resident and was not identified as requiring a Hoyer lift at that time. Another CNA described assisting with dressing and transferring the resident into the wheelchair using a stand-and-pivot method and stated that a Hoyer lift was not used. The facility’s Accident/Incident investigation did not include a review of the resident’s care plan for transfer requirements, did not evaluate the Hoyer lift transfer, did not include interviews with staff from all shifts involved in the resident’s care and transfers, and did not identify the transfer requirements, staff involved across shifts, or the circumstances surrounding the transfer to determine how the fracture occurred.