Failure to Investigate and Document Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and document an alleged violation of neglect involving a resident who fell from a bath chair and sustained a left femoral neck (hip) fracture. The incident occurred when the resident was not secured in the bath chair with the safety strap during bathing. The certified nurse aide (CNA) responsible for the resident admitted to not using the safety strap, and the resident fell after reaching for the door on the tub. Following the fall, the CNAs used a mechanical lift to transfer the resident from the floor back to the bath chair without a nurse's assessment, and then later transferred the resident to her wheelchair using a sit-to-stand lift. Staff interviews revealed inconsistencies and omissions in the facility's investigation. The CNAs involved described the sequence of events, including the lack of use of the safety strap and the delay in obtaining additional help. The nurse who later entered the room was informed of the fall only after noticing a lift sheet under the resident and questioning the situation. Nursing progress notes documented the fall, the resident's subsequent pain, and the eventual transfer to the hospital for evaluation and treatment of the hip fracture. The facility's internal investigation did not include all relevant details discovered during staff interviews, such as the failure to secure the resident in the bath chair and the improper transfer of the resident post-fall without prior nursing assessment. The investigation summary concluded there was no willful intent to neglect, attributing the fall to the resident's spontaneous movement, but failed to address the staff actions and omissions that contributed to the incident.