Failure to Investigate and Document Alleged Injury During Resident Repositioning
Penalty
Summary
The facility failed to thoroughly investigate an allegation of injury for one resident. The resident, who had diagnoses including Parkinson's Disease, functional quadriplegia, and acute kidney failure, was cognitively intact and dependent on staff for bed mobility and transfers. The resident complained of right shoulder pain, and an in-house x-ray revealed a displaced scapular fracture and osteopenia. The resident was subsequently transferred to the hospital, where the hospital's history and physical documented that the resident reported hearing a pop in their right shoulder while being repositioned by staff. Despite this, the facility did not provide any incident or accident report related to the event when requested by surveyors. Interviews and record reviews revealed that the facility did not complete an official investigation into the incident. The administrator acknowledged that while the resident's complaint was discussed and aides were questioned, no formal investigation or documentation was completed. The family representative also reported the incident to the DON, who stated an internal investigation would be conducted, but no formal complaint was filed and no documentation was produced. The lack of a thorough investigation and absence of required incident reporting led to the deficiency.