Incomplete Investigation of Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who alleged being dropped by ambulance transport on two separate occasions. The incident was initially reported after the resident experienced pain in their elbow and shoulder while reaching for a urinal, which led to a hospital transfer. Upon return, the resident later disclosed to staff that they had been dropped by both transport teams but had not reported it earlier to avoid getting anyone in trouble. The facility's investigation did not include immediate assessment by a Registered Nurse after the fall was reported, and only a Licensed Practical Nurse performed a skin assessment. Additionally, there was no evidence that the facility made an effort to contact the second transport company to obtain statements or further investigate the allegation. The resident involved had significant medical conditions, including multiple myeloma, fatigue fracture of the vertebrae, pathological fracture in neoplastic disease, and malignant neoplasm of the bone. The resident was fully cognitively intact and dependent on staff for all activities of daily living, including transfers. The facility's policy required that investigations include interviews with staff, residents, and witnesses, with statements attached to the incident report and kept on file. However, the investigation was incomplete, lacking both a Registered Nurse assessment and documentation of contact with the second transport company.