Failure to Investigate Potential Neglect After Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure a potential allegation of neglect was thoroughly investigated after a resident sustained bilateral femur fractures during a transfer. On the date of the incident, the resident, who had moderate cognitive impairment and multiple medical diagnoses including osteoporosis and a left artificial hip joint, was transferred from the edge of the bed using a sit-to-stand lift by a CNA. The resident's care plan at the time required a two-person assist for all transfers with a sit-to-stand lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent bilateral distal femur fractures that required surgical intervention. The incident report did not include an interview with the resident regarding the transfer or the equipment used, nor did it document the CNA's technique during the transfer. Further, the facility did not conduct interviews with other residents to determine if there were additional allegations of neglect or improper transfers involving the CNA. Both the Nursing Home Administrator and the Director of Nursing confirmed that resident interviews were not completed as part of the investigation, and the facility-reported incident documentation lacked a summary of an interview with the affected resident. This failure to follow the facility's abuse, neglect, and exploitation policy resulted in an incomplete investigation of the potential neglect.