Failure to Investigate and Address Improper Transfer Leading to Resident Fall
Penalty
Summary
The facility failed to promptly and thoroughly investigate an incident of potential neglect involving a resident with bilateral below-the-knee amputations and a documented need for two-person assistance during transfers. Despite care plan instructions specifying the use of a sliding board and two staff members for all transfers, the resident was transferred by a single staff member, and the wheelchair was not locked, resulting in a fall onto the resident's right amputated leg. Previous falls had occurred without new interventions being implemented, and the resident was noted to be cognitively intact at the time of the incident. Following the fall, the facility did not conduct a comprehensive investigation as required by its abuse, neglect, and exploitation policy. There was no documentation of witness statements, staff or resident interviews, or identification of the staff member involved in the transfer. The Director of Nursing confirmed that no investigation consistent with facility policy was completed, and no analysis or corrective actions were documented to address the incident or prevent recurrence. The lack of timely and complete investigation and failure to implement corrective measures constituted a deficiency in responding to alleged violations.