Failure to Thoroughly Investigate Resident Accident and Change in Condition
Penalty
Summary
The facility failed to thoroughly investigate an accident involving one of four residents reviewed for accidents. On the night in question, a resident with severe cognitive impairment, a history of falls, and generalized anxiety disorder was found unresponsive on the floor next to their bed. The resident was only responsive to painful stimuli and exhibited uncontrollable shaking. Staff were unable to obtain vital signs, including body temperature, which was too low to be read by a thermometer. The resident was left for an undetermined amount of time without care, and there was no documentation of a thorough investigation to determine if abuse or neglect had occurred. Facility policy required that all accidents or incidents be investigated and reported, including details such as the date, time, nature of injury, circumstances, and the resident's condition. However, the investigation report did not address key factors such as the length of time the resident was on the floor or the cause of the resident's hypothermia. There were discrepancies between the physician's progress note and the nursing documentation, particularly regarding the resident's vital signs and mental status, which were not reconciled in the investigation. Additionally, the facility did not interview the resident's alert and oriented roommate, who may have provided relevant information about the incident. Interviews with staff revealed that critical information, such as the resident being found naked, cold, and shivering, was not communicated to the DON during the initial investigation. The hospital emergency department documented that the resident presented with hypothermia, tachycardia, tachypnea, and hypoxia, and the receiving nurse noted there was no plausible explanation provided for the hypothermia. The facility failed to conduct a comprehensive investigation as required by its own policies and regulatory requirements.