Failure to Fully Investigate Resident Injuries and Possible Neglect
Penalty
Summary
The facility failed to fully investigate injuries sustained by three residents, as required by its policy on abuse, neglect, and injuries of unknown origin. For one resident with severe cognitive impairment and a history of falls, documentation showed the resident fell from a wheelchair after abruptly slamming his feet down and grabbing a hallway railing, resulting in a forehead injury. Although staff documented the incident and assessed the injury, the investigation did not address all aspects of the event as required by policy. Another resident, with diagnoses including debility and a history of falls, slid out of a wheelchair while being assisted by a CNA. The incident was attributed to a towel on the wheelchair seat, but the facility did not have a current physician's order for the resident's transfer status, and the investigation into the incident was incomplete. Documentation indicated that the resident was not assessed for chair/bed-to-chair transfers due to medical or safety concerns, and there was a lack of follow-up on transfer orders. A third resident, also with severe cognitive impairment, was found to have a skin tear on the right arm with no documentation of when or how the injury occurred. The facility was unable to provide a complete investigation into the injury of unknown origin, offering only an incident report without details on the circumstances, staff involved, or employee statements. The Director of Nursing confirmed that the facility did not fully investigate these injuries, resulting in a failure to respond appropriately to possible neglect and injuries of unknown origin.