Failure to Investigate Fall and Implement Care Plan Interventions
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident's fall with minor injury and did not determine whether neglect occurred. The resident, who had end-stage renal disease, bilateral below-the-knee amputations, and required dialysis, was care planned and had physician orders for all transfers to be performed with a mechanical lift and two staff members. Despite these orders, an agency nurse aide attempted to transfer the resident manually and alone, resulting in the resident's stump becoming stuck in the wheelchair arm and a subsequent fall to the floor. The incident occurred in the presence of floor clutter and spilled water, which contributed to the event. The facility's investigation did not include a statement from the resident at the time of the incident, nor did it identify or document that the mechanical lift was not used and that only one staff member was involved in the transfer. The investigation also failed to evaluate whether the resident's care plan was implemented as directed or to recognize the deviation from established protocols. The nurse aide involved had completed required training and was deemed competent, yet did not follow the care plan or physician's orders during the transfer. Following the fall, the resident experienced rib pain and required pain management, with a physician later diagnosing a rib contusion. The facility did not provide evidence of a comprehensive investigation to rule out neglect or mistreatment, nor did it identify the lack of adherence to planned interventions or implement measures to prevent recurrence. The deficiency was cited under relevant federal and state regulations for failure to protect residents from neglect and to ensure care plans are followed.