Failure to Investigate Resident's Allegation of Injury During Transfer
Penalty
Summary
The facility failed to thoroughly investigate an allegation made by a resident who reported being physically injured by staff during a transfer with a Hoyer lift. The resident complained of soreness in the right hip following the incident and later reported to a physical therapy assistant that aides had hurt them. The physical therapy assistant informed the Director of Therapy but did not notify other administrative staff, and the resident was not asked to elaborate on the allegation. Documentation shows that the concern was not escalated or formally investigated as required for abuse allegations. Further review revealed that a nursing unit manager addressed some of the resident's concerns days later, including instructing staff to be more gentle and educating the resident on safety procedures, but there was no documentation of staff education or follow-up regarding the abuse allegation. The resident subsequently requested to go to the emergency room, where they were admitted with diagnoses including atypical chest pain, ambulatory dysfunction, and neglect of an adult. The facility's records did not show that the required investigation or documentation of the alleged abuse was completed.