Failure to Timely Investigate and Update Care Plan After Resident Accident
Penalty
Summary
The facility failed to timely investigate an accident and update the care plan for a resident who reported her head was bumped during a shower transfer. The resident, who had a history of cerebral infarction, hemiplegia, dysphagia, lack of coordination, and required extensive assistance with activities of daily living, stated that after being assisted into a shower chair by two CNAs, one left the room and the other continued with the shower. The resident reported that her head was bumped when the staff pushed her shower chair too quickly around a bathroom corner, causing significant pain at the site of a previous incision. The incident was reported by the resident's husband to an LPN on the same day, but no investigation or care plan update was documented in the electronic medical record at that time. Interviews with the resident, her husband, and multiple staff members revealed that no one was questioned about the incident until over a month later. The DON confirmed that although the incident was reported, no investigation was initiated because there was no visible injury. The facility's policy required that incident reports be completed promptly and investigations started within 24 hours, with findings and interventions documented and shared with relevant staff. This process was not followed, resulting in a lack of timely investigation and care plan revision after the reported accident.