Failure to Document Thorough Investigation After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an allegation of neglect following a fall incident involving a resident. The resident, who had multiple complex medical diagnoses including type 2 diabetes, right femur fracture, asthma, major depressive disorder, hemiplegia, respiratory failure, and cognitive communication deficit, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in complaints of pain and a visible injury, prompting an abuse investigation and notification to the State Survey Agency. The facility's abuse investigation documentation was incomplete, lacking records of interviews with the staff members involved in the transfer and the resident. Additionally, the investigation summary referenced an interview with the resident, but no documentation of this interview was found. The date of the incident was also incorrectly documented in the investigation. The Director of Nursing confirmed that the investigation records did not contain the necessary interviews to rule out neglect, and it was not evident from the documentation that a thorough investigation had been conducted.