Failure to Investigate Injury of Unknown Origin for Dependent Resident
Penalty
Summary
The facility failed to follow its Abuse Reporting and Investigation policy, dated November 2025, which required that injuries of unknown origin be investigated to rule out potential abuse. Clinical record review for Resident 7, who had diagnoses including anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, and who was cognitively impaired and required staff assistance for bed mobility per a recent MDS assessment, showed that on January 29, 2026, a nurse documented an abrasion on the resident’s left knee measuring 2.3 cm by 1.3 cm with an unknown origin. There was no documented evidence that any investigation was conducted to determine the cause of this injury or to rule out potential abuse. In an interview on March 5, 2026, the Regional Clinical Director confirmed that there was no documentation of an investigation related to this injury of unknown origin, resulting in a deficiency under 28 Pa. Code 211.10(d) and 211.12(d)(1)(5).
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