Failure to Investigate Alleged Violations and Assess Resident After Improper Transfer
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for a resident who required two-person assistance with a mechanical lift for transfers. A Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident nearly falling. Despite the care plan violation, the resident was not assessed by a qualified professional following the incident, and was later found with skin tears on both legs. The resident, who had diagnoses including atrial fibrillation, long-term use of anticoagulants, and progressive neuropathy, was care planned for two-person assistance with a mechanical lift. However, CNA #29 attempted a one-person transfer, which was against the care plan. The CNA reported that the resident became combative during the transfer, nearly resulting in a fall. Despite the incident, there was no documented evidence that the resident was assessed by a qualified professional immediately following the transfer. Subsequently, the resident was found with skin tears and a bruise, but the origin of these injuries was unknown. The facility's investigation did not determine when the injuries occurred, and there was no documentation of an assessment following the improper transfer. The Director of Nursing was not immediately notified of the incident, and the registered nurse on duty was not informed, which was against the facility's protocol for handling such incidents.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident identified as #371 has since been discharged from the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Reviewed and investigated the previous 30 days of accidents/incidents regarding skin impairments. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Educate administrative nursing staff on the Recognizing and reporting elder abuse/neglect criteria policy, as well as education on conducting thorough investigations. The policy addresses completion of an assessment of the resident for injuries and has been updated to include documentation of the assessment in the accident/incident report. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? All skin impairments of unknown origin will be reviewed by the Director of Quality Management and reported on during QAPI monthly for three months and quarterly thereafter. The date for correction and the title of the person responsible for correction of each deficiency: Administrator.