Failure to Investigate Fall and Collaborate After Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident remained free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, after a resident experienced a fall from bed, the facility's investigative report did not include a possible cause for the injury in the initial investigation statement, despite the facility being aware of the cause. The Director of Nursing (DON) confirmed that the cause of the fracture should have been documented in the investigation statement, but it was omitted. Additionally, after the resident was found to have sustained an acute, displaced comminuted distal femoral shaft fracture as revealed by a radiology report, there was no documented evidence that the Interdisciplinary Team (IDT) collaborated or held a meeting to review the resident's change in condition. The DON verified that the IDT meeting and documentation should have occurred following the x-ray results, but this did not happen.