Failure to Investigate and Prevent Further Harm After Resident Fall
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for one resident. Specifically, a resident with severe cognitive impairment, multiple comorbidities including vascular parkinsonism, dementia, and significant mobility deficits, sustained a femur fracture during a transfer performed by a CNA. The resident required substantial to maximal assistance for transfers and was at risk for falls, as documented in the care plan. On the day of the incident, the CNA attempted a stand and pivot transfer without using a gait belt, contrary to facility expectations. The CNA reported that the resident's leg slid and she helped him to the ground, after which the resident was found to have right hip tenderness, swelling, and severe pain, leading to a hospital transfer where a femoral shaft fracture was diagnosed. There was no documentation of statements from the CNA or the LVN present at the time of the fall, and no Post-Incident Report (PIR) was provided for the event. Interviews with facility leadership revealed a lack of clarity regarding the specifics of the transfer, including whether a gait belt was used and the CNA's positioning. The Director of Nursing and Administrator were not fully aware of the details and did not ensure a thorough investigation was conducted as outlined in the facility's abuse prevention policy, which requires interviews with all involved parties and documentation of the investigation's results. The absence of a comprehensive investigation and documentation following the incident constituted the deficiency.