Failure to Investigate, Assess, and Report Resident Injury
Penalty
Summary
The facility failed to provide evidence of a thorough investigation, assessment, and appropriate reporting of an incident involving a resident who sustained new bruises of suspected origin. The facility's policy requires that all alleged violations, including abuse or neglect, be thoroughly investigated, with proper documentation and reporting to state and federal agencies as appropriate. In this case, there was no documented assessment of the resident's injury, no incident report, and no evidence of an internal investigation or federal reporting, despite the incident being reported to the state agency. The resident involved was admitted for a nondisplaced intertrochanteric fracture of the right femur and was documented as mentally intact with a BIMS score of 15. The incident in question involved the resident receiving two bruises during a stand pivot transfer from a wheelchair to bed, with the resident stating that the aide was rushed and did not stop when asked. The resident requested that the aide no longer care for her, and the aide was subsequently reassigned. Staff interviews confirmed that the incident was reported to the administrator, but there was no evidence of a clinical assessment of the bruises or a formal incident report being completed. Administrative and clinical record reviews revealed that the facility did not follow its own policy for incident and reportable event management. There was no documentation of the assessment of the resident's injuries, no incident report in the logs, and no evidence of an internal investigation or staff education related to the incident. The administrator was unable to provide documentation of the investigation or reporting, and staff interviews indicated a lack of recall regarding the assessment or documentation of the resident's injuries. The state agency's investigation substantiated the allegations, confirming that the resident sustained physical injuries during the transfer and that the facility did not have the required documentation or evidence of a thorough investigation.