R0406

Failure to Conduct Thorough Investigation After Resident Injury

Optalis Health And Rehabilitation Of TroyTroy, Michigan Survey Completed on 04-09-2025

Summary

A resident with a history of lumbar vertebra fracture and requiring two-person assistance with bed mobility sustained a distal tibia and fibula fracture of unknown origin while receiving care from an agency CNA. The resident reported that the aide moved them too quickly during a brief change, causing their right leg to come off the mattress and hit the floor. The resident did not immediately report the incident to nursing staff due to fear, but later informed a nurse manager after experiencing increased pain. The clinical record indicated the resident was alert, cognitively intact, and had ongoing mobility and incontinence needs.

The facility's investigation into the incident was incomplete. Only one witness statement was obtained, from the agency CNA involved, who denied the resident's leg hit the floor and stated the resident was already complaining of pain. There was no documentation of interviews with other staff or residents, and no evidence that all relevant parties were questioned. The investigation documents provided to the State Agency and reviewed during the survey were the same, lacking additional statements or supporting evidence.

During interviews with facility leadership, it was confirmed that the investigation did not include comprehensive interviews with nursing staff or like-residents, and there was no documentation of education or disciplinary action for staff involved. The administrator acknowledged that the aide did not follow the plan of care, which required two-person assistance, and that the investigation was incomplete. No further documentation or follow-up was provided by the end of the survey.

Penalty

No penalty information released