Failure to Investigate Resident Fracture
Penalty
Summary
The facility failed to thoroughly investigate a fracture sustained by one resident. According to the facility's policy, the Director of Nursing (DON) is responsible for directing investigations into possible abuse or injury. The resident in question, who was cognitively intact and required varying levels of assistance with daily activities, reported using a sink to assist in standing and subsequently experienced pain and a popping sound in the left shoulder. The resident was sent to the emergency room, where initial X-rays were reported as normal, but the resident was admitted for an exacerbation of congestive heart failure. Upon the resident's return to the facility, documentation indicated diagnoses of a left acromion fracture and a compression fracture of the 8th thoracic vertebra. The facility was notified by the resident's provider of these injuries, but the DON confirmed that no investigation was conducted to determine the possible or probable cause of the compression fracture. This lack of investigation was contrary to facility policy and regulatory requirements to respond appropriately to all alleged violations or injuries.