Neglect Leads to Resident's Dislocated Shoulder
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in a dislocated shoulder for one resident. The resident, who was cognitively impaired and dependent on staff for all daily care needs, exhibited increased behaviors and requested pain relief. Nursing notes indicated that the resident had multiple bruises on her upper arm, which were painful to touch, and the bruising and swelling worsened over time. An x-ray confirmed a dislocated left shoulder. The facility's investigation revealed that a nurse aide forcibly moved the resident's arm while providing care, causing the dislocation. A witness statement confirmed the forceful movement, and the resident immediately complained of pain and tingling in her fingers. A registered nurse assessed the resident but did not examine the upper arm or shoulder due to the resident's resistance. The Director of Nursing confirmed the nurse aide's actions led to the injury.
Plan Of Correction
1. Nurse Aid 2 was immediately suspended pending investigation of claims of abuse. After findings of abuse were substantiated, her employment at FCMC was terminated on 11/25/2024. 2. Facility completed on the spot education related to Residents' Right to be free from Abuse and Neglect F600 and Reporting Requirements F607, as well as FCMC policy on how to report. Education was completed on 11/26/2024. 3. Contracted Virtual In-Service training on F600 Freedom from abuse and neglect and misappropriation. Staff not able to attend in person were required to watch the recorded session and complete a post-test in HealthStream. Virtual Training was completed on 11/26/24. HealthStream Education was completed on 12/4/24. 4. Directed In-Service Training for all staff is contracted to be completed on Friday, 12/20/2024. Training will include F600 42 CFR. 6. Attendance to the Directed In-Service training will be monitored by the administrator, and compliance will be reported to the Quality Assurance and Performance Improvement committee by email.