Failure to Report and Assess Resident Injury Following Transfer Incident
Penalty
Summary
The facility failed to follow its policy and procedure regarding significant changes of condition for a resident with a history of hemiplegia, hemiparesis, diabetes, and muscle atrophy. During a morning shift, a Certified Nursing Assistant (CNA) transferred the resident from a shower chair to bed, during which the resident's left leg, which was paralyzed, became caught on the shower chair. The CNA did not report this incident to a charge nurse or supervisor, stating that the resident did not complain of pain at the time. However, another CNA later heard the resident complain of left foot pain and informed a Registered Nurse (RN), who administered Tylenol and documented its effectiveness, but did not further assess or document the incident involving the leg. Later that day, the resident complained of pelvic and left knee pain, and bruising was observed on the left lateral leg. The physician was notified, and an x-ray was ordered, which revealed a depressed lateral tibial plateau fracture. Interviews with facility leadership confirmed that the incident should have been reported and assessed as a significant change of condition, with appropriate documentation and physician notification. The facility's policy requires that any change in a resident's condition, such as a decline in physical function or an incident, be reported to a licensed nurse or supervisor, who must then assess, document, and communicate with the provider as needed. In this case, the failure to report and assess the incident involving the resident's leg delayed necessary care and services, as the injury was not promptly identified or addressed according to policy.