Failure to Investigate Alleged Injury During Resident Repositioning
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate an allegation of injury for one resident. The resident, who had diagnoses including Parkinson's Disease, functional quadriplegia, and acute kidney failure, was cognitively intact and dependent on staff for bed mobility and transfers. The resident complained of right shoulder pain, and an x-ray revealed a displaced scapular fracture and osteopenia. The hospital history and physical documented that the resident reported hearing a pop in their right shoulder while being repositioned by staff. Despite this, the facility did not provide any incident or accident report when requested by surveyors, and the administrator confirmed there were no such reports on file for the relevant period. Further review and interviews revealed that the facility did not conduct or document a formal investigation into the incident. The administrator stated that although the resident's family reported concerns to the DON and were told an internal investigation would be completed, there was no official investigation or documentation found. Staff interviews indicated that aides denied being rough with the resident, and the administrator believed the resident was at their baseline with no increased pain. The lack of a documented investigation and incident report constituted a failure to respond appropriately to an alleged violation.