Failure to Investigate Possible Neglect After Resident Injury
Penalty
Summary
The facility failed to fully investigate an incident involving a resident who sustained injuries after attempting to self-transfer to the toilet. The resident, who had diagnoses including arthritis, Parkinson's disease, and depression, was care planned as high risk for falls and required assistance of two staff for transfers, with safety interventions such as bed and chair alarms and a low bed. On the day of the incident, the resident was found by a nursing assistant standing at the toilet, self-transferring. The resident requested privacy, and staff placed the call bell in her hand before leaving the room to respond to another resident's alarm. Shortly after, the resident was found on the floor outside the bathroom, complaining of pain in her right arm, wrist, and shoulder. Subsequent assessments and imaging revealed that the resident had sustained a right elbow dislocation, a fracture of the distal radius, and a fracture of the coronoid process. The resident required hospital evaluation and orthopedic intervention, including conscious sedation and reduction of the dislocation. The care plan for the resident included prompt response to requests for assistance and provision of a bedpan or bedside commode as needed, but the incident report indicated that the resident was left alone in the bathroom after requesting privacy, and staff were diverted to another resident's alarm. The facility's policy requires that all incidents of abuse, neglect, or injuries of unknown source be thoroughly investigated and documented, including notification of the Administrator or DON and reporting to the state health department. However, review of facility-submitted reports showed that the incident was not investigated as a possible case of neglect, nor was an allegation of neglect documented. The DON confirmed during interview that the facility failed to fully investigate the incident to eliminate possible neglect.