Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident in which a resident experienced an unwitnessed fall during a mechanical lift transfer, resulting in a tibial tuberosity fracture. The incident occurred when a CNA placed a Hoyer sling under the resident and left the room to get assistance, returning to find the resident on the floor. Documentation showed that the CNA involved would not be able to work at the facility due to not following protocol, but the investigation records lacked a summary of findings, root cause analysis, or a determination regarding the likelihood of abuse or neglect contributing to the incident. Interviews with facility leadership, including the Director of Nursing and Director of Health Services, confirmed that the investigation did not include a completed summary or a clear ruling out of abuse or neglect, contrary to both facility policy and regulatory requirements. The facility's own policies require prompt and thorough investigations, including gathering witness statements, root cause analysis, and a summary of findings, none of which were fully documented in this case.