F0610

D

Failure to Thoroughly Investigate Resident’s Knee Fracture of Unknown Source

Saint Helens, Oregon Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the facility’s failure to conduct a thorough investigation into an injury of unknown source for one resident. The resident, admitted in 2/2013, had an anoxic brain injury and a care plan dated 1/12/25 documenting impaired cognitive function, poor impulse control, difficulty with self-expression, decision making, and mental status. A 3/31/25 MDS showed a BIMS score of 0/0, indicating severe cognitive impairment. On 10/11/25, staff first noted swelling of the resident’s right knee. The DNS (Staff 2) reported that upon her examination at that time, she noted no bruising and concluded the injury was likely self-inflicted due to the resident’s poor impulse control.

An x-ray ordered on 10/13/25 revealed a right knee fracture. A facility investigation report dated 10/23/25 documented swelling and bruising of the right knee and concluded the injuries were likely from the resident kicking the bed footboard. However, an RN (Staff 26) stated that when she was informed of the swelling and examined the resident, she observed significant bruising and swelling and ordered the x-ray that confirmed the fracture. Staff 26 also stated the resident did not know how the injury occurred and that she did not believe it was self-inflicted. There was no documented evidence that the facility completed a thorough investigation into this injury of unknown source, and the Administrator (Staff 1) confirmed that the facility did not thoroughly investigate the resident’s injury.