Failure to Prevent Injury of Unknown Origin Resulting in Fractured Leg
Penalty
Summary
A deficiency occurred when a resident with significant medical vulnerabilities, including dementia, Alzheimer's, protein malnutrition, and palliative care needs, sustained a fractured tibia and fibula of the right leg while residing in the facility. The resident was nonverbal, frail, and dependent on staff for all care, including transfers with a mechanical lift requiring two staff members per facility protocol. However, hospice staff, who also provided care, reportedly used only one staff member for transfers. The resident was often positioned in a Broda chair, with observations noting her leaning to one side and her right heel positioned in the leg extension crack of the chair. Documentation from certified nursing assistants indicated no concerns with the resident's positioning or skin condition in the days leading up to the discovery of the injury. On the day the injury was identified, a hospice staff member noticed bruising on the resident's right ankle, which had not been present previously. Subsequent assessment revealed swelling and yellow/greenish bruising, and an X-ray confirmed fractures of the tibia and fibula. The cause of the injury could not be determined, but it was suggested by facility management and the resident's family that improper securing of the resident's legs during movement in the Broda chair or accidental bumping of the foot/ankle during transfers or transport may have contributed. Interviews with facility and hospice staff highlighted inconsistencies in care coordination and communication. Hospice aides did not consistently communicate with facility staff regarding the care provided, and there were differences in transfer practices between hospice and facility staff. The facility's investigation did not identify a specific cause for the injury, and the injury was classified as of unknown origin. The facility's abuse prevention policy prohibits neglect, but the lack of adequate supervision and coordination between facility and hospice staff led to the resident sustaining a significant injury.