F0610

E

Failure to Thoroughly Investigate Injuries of Unknown Origin for Two Residents

Liberty, New York Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate accidents and injuries of unknown origin for two residents, in accordance with its own "Accidents and Incidents - Investigating and Reporting" policy and 10 NYCRR 415.4(b)(3). The policy requires that incident/accident reports include the date and time of the event, the nature of the injury, the circumstances surrounding the incident, and the location, and that the Nurse Supervisor/Charge Nurse or department director complete and submit the report to the DON within 24 hours, with the Administrator also receiving a copy. For both residents, the facility did not identify how the injuries occurred, did not complete a comprehensive investigation, and in one case did not report the incident to the New York State Department of Health.

For the first resident, who had diagnoses including muscle weakness, insomnia, and bilateral glaucoma and was documented as severely cognitively impaired, staff noted a bruise on the right hip after the resident’s return from an eye surgery hospitalization. Prior to this, the resident required supervision or touching assistance for most ADLs, was independent in rolling, and needed only setup or cleanup help for chair-to-bed transfers. After returning from eye surgery, documentation indicated the resident had an eye patch, was to remain NPO after midnight for surgery, was not to ambulate without assistance, and had a bed alarm in place. On the date of the incident, a CNA called the nurse after finding a light to dark purple bruise, about the size of a 50‑cent piece, on the resident’s right hip; the resident was unable to describe what happened and complained of pain and inability to stand, despite previously being able to ambulate for surgery.

The incident report for this first resident documented that an x‑ray was ordered, the provider, DON, and family were notified, and the resident was sent to the ED per family request. The subsequent x‑ray showed a displaced acute traumatic fracture of the right femoral neck, with no aggressive osseous lesion or erosions. The incident report contained a later note referencing the resident’s limited medical history, long‑standing tobacco use, and osteoporosis, and concluded that there was no evidence of abuse, neglect, or mistreatment, and that the resident had recently been at the hospital alone for eye surgery. However, there were no staff statements on the report, no documented look‑back of staff who provided care, no explanation of how the injury occurred, and no facility investigation or report to the New York State Department of Health. The Medical Director stated they would have expected more investigation, including a look‑back of staff, and acknowledged they had no idea what caused the incident.

For the second resident, who had Alzheimer’s disease, intermittent explosive disorder, generalized anxiety disorder, severe cognitive impairment, incontinence, wheelchair mobility, and dependence on staff for transfers and bed mobility, staff discovered a large purple bruise with mild swelling on the left lower leg. The resident laughed when asked what occurred, but a CNA reported that the resident had been complaining of pain from the time the bruise was found, saying "Ow, ow, that hurts," despite not being very vocal generally. The initial Accident/Incident report, completed by the Infection Control Nurse, described mild discomfort on palpation, mild swelling without redness or warmth, and a pain level of 2 with facial grimacing. The resident was seen by a Nurse Practitioner with no further orders at that time, and the report’s root cause analysis concluded the bruise was from bumping the Hoyer during transfer, yet there were no supporting staff statements documented.

Subsequent documentation showed that the Medical Director later ordered an x‑ray of the left lower extremity, and when the x‑ray could not be completed, the resident was sent to the ED, where a fracture of the left tibia and fibula was diagnosed. The CNA who found the bruise stated they did not know how it happened, that the resident was transferred with a Hoyer, that many residents on the unit required Hoyer transfers, and that no one knew how such a large, swollen, green and purple bruise that wrapped around the leg had gone unnoticed earlier. The DON stated they did not know how the Infection Control Nurse concluded the bruise was from bumping the Hoyer, given the absence of statements in the Accident/Incident report, and also stated they did not know why they were not made aware earlier. An injury of unknown origin was reported to the Infection Control Nurse on the date the bruise was found, and the DON submitted a report to the New York State Department of Health several days later, but the facility did not complete a thorough investigation into the circumstances of the injury as required by policy.