Failure to Investigate Injury of Unknown Origin and Follow Transfer Protocols
Penalty
Summary
The facility failed to initiate a thorough investigation into an injury of unknown origin for one resident. The resident, who was cognitively intact and had diagnoses including bipolar disorder, enteropathy, and hypertension, was observed by her son to have a small bulge on her left shoulder. Medical evaluation and an X-ray confirmed a dislocated shoulder. The resident reported that the injury occurred during a fall in August and denied experiencing pain or harm from others. Despite this, the facility did not conduct a comprehensive investigation into the circumstances surrounding the injury. Further review revealed that physician orders required the resident to be transferred with the assistance of two staff members, but records indicated she was transferred by only one staff person. Interviews with the NHA and DON confirmed they were unaware of the concerns regarding the injury and the transfer process. The lack of a thorough investigation and failure to follow transfer protocols constituted a deficiency under the cited regulations.