Failure to Investigate and Document Alleged Fall and Injury
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for one resident reviewed for neglect. Specifically, the facility did not thoroughly investigate a reported fall that could have been related to a confirmed right femur fracture. Documentation showed that the resident, who had severe cognitive impairment and multiple risk factors for falls, was involved in an incident in the restroom where staff had differing accounts of whether a fall occurred. CNA B reported that the resident fell and was lifted from the floor, while CNA A denied a fall occurred. The facility did not obtain statements from all involved staff, and there was no incident report or documentation of a fall in the facility's records for the relevant period. The resident's medical history included unspecified dementia, need for assistance with personal care, age-related physical debility, syncope, muscle wasting, and muscle weakness. The care plan identified the resident as being at risk for falls due to gait and balance problems, incontinence, poor safety awareness, dementia, and a history of syncope. After the restroom incident, the resident complained of right upper leg pain, and a subsequent x-ray confirmed a right femur fracture, leading to hospital admission for surgery. Despite these events, the facility did not document a thorough investigation or protective measures during the investigation period. Interviews with staff revealed inconsistencies in the accounts of the incident, with the Director of Nursing and Administrator both acknowledging uncertainty about whether a fall had occurred. The Administrator chose to rely on the statement that no fall occurred and did not follow up on the contrary account. The facility's policy required immediate investigation of alleged abuse, neglect, or exploitation, but this was not followed, as evidenced by the lack of comprehensive documentation, failure to obtain all relevant staff statements, and absence of an incident report for the event.