Failure to Thoroughly Investigate Injury of Unknown Origin and Document Findings
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an injury of unknown origin involving a resident with severe cognitive impairment and extensive care needs. The resident, admitted with diagnoses including Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease, required substantial/maximal assistance with eating and bed mobility and was dependent on staff for bathing, hygiene, and transfers. The resident’s care plan included monitoring for skin concerns during care. On the date of the incident, the resident’s daughter observed a light purple discoloration/bruise on the resident’s right cheek while staff were assisting with lunch and reported it to an RN, who had not noticed it earlier and reported it to the DON. The DON’s incident report suggested the area could have been caused by the resident’s cheek resting on a side rail during incontinence care, but the nature of the incident was not clearly documented. The facility’s investigative process was incomplete and poorly documented. Staff interviews did not reveal any evidence of the resident’s face contacting the bed rail, and the interviews with multiple CNAs lacked dates and times. One CNA’s witness statement, obtained by phone, did not include her last name or title. No physical assessments for abuse were conducted on non-interviewable residents to determine if others were affected. The incident/accident log contained no entry for the resident’s cheek bruise, and the resident’s medical record had no documentation of the bruise or a skin assessment on the date it was identified. The DON confirmed that the incident report constituted the full investigation, that no other residents were assessed for injuries, that no written staff education was completed for prevention of recurrence, and that there was no medical record documentation of the discoloration/bruise, despite facility policy requiring all abuse investigations to be thoroughly investigated with written statements from all involved parties.
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