Failure to Investigate and Document Resident Injury During Transportation
Penalty
Summary
The facility failed to ensure a thorough investigation and proper documentation following an incident in which a resident reported hitting his head on the ceiling of a facility van while being transported over speed bumps to a medical appointment. The resident, who had diagnoses including malnutrition, osteomyelitis, muscle weakness, arthritis, kidney disease, and diabetes, was cognitively intact and independent in daily activities. According to progress notes and staff interviews, the resident reported the incident to social services the day after it occurred, stating he had to bend to avoid hitting his head and that there was little space between his head and the van ceiling. Despite the report, there was no documented evidence in the medical record that the resident was assessed for injury after the incident, nor was there a completed investigation as required by facility policy. While witness statements from staff referenced the incident and mentioned a head-to-toe assessment and normal neurological checks, these assessments were not documented in the medical record. The facility's policy required documentation of accidents, resident assessments, and investigation summaries, but these steps were not followed in this case.