Failure to Prevent Neglect and Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had diagnoses including osteoarthritis, anxiety, dementia, and Alzheimer's disease, was dependent on staff for transfers and required the use of a mechanical lift as per her care plan. On one occasion, two hospice CNAs transferred the resident without using the required mechanical lift, during which they heard a pop in her shoulder. This incident was not reported to facility staff, and the hospice nurse who was informed also failed to notify facility staff. Subsequently, the resident was found with multiple bruises on her right shoulder and upper arm, and later complained of pain in the same area. Despite these findings, the facility did not promptly notify the Medical Director, only sending a fax approximately 12 hours after the bruising was identified. The facility also failed to obtain timely witness statements from hospice staff and did not provide documentation of interviews or assessments related to the incident until after a fracture was confirmed by X-ray ten days later. The investigation revealed that the facility was unable to provide key documentation, including the hospice plan of care, hospice physician orders, and records of staff education or interviews following the incident. The administrator acknowledged that the root cause was the failure to use the mechanical lift during transfer, but could not produce documentation of the investigation or education provided. The lack of timely reporting, documentation, and adherence to the resident's care plan led to a delay in diagnosis and treatment of a displaced right humerus fracture.