Failure to Thoroughly Investigate Dislocated Hip Injury of Unknown Source
Penalty
Summary
Surveyors found that the facility failed to conduct a thorough and complete investigation to rule out abuse, neglect, or mistreatment after a resident with a right hip replacement was discovered to have an acute posterior dislocation of the femoral head prosthesis. The resident had severe cognitive impairment, dementia, osteoarthritis, and required extensive assistance with activities of daily living, including two-person assistance for transfers. A physician note documented the resident was seen for lethargy and right thigh tenderness, and an X-ray confirmed the acute dislocation. The incident report classified the injury as having an unknown date, time, and location, and noted the resident was unable to explain what happened. The facility’s abuse policy required classification of injuries of unknown source when not observed, not explainable by the resident, or suspicious by extent or location. The investigation conducted by the facility consisted primarily of obtaining written statements from CNAs, LPNs, and therapy staff, all of whom reported no knowledge of any fall or incident and did not document the specific care they provided, including transfers or other activities. The investigative summary concluded that the dislocation was most likely related to the resident’s history of hip arthroplasty, osteoarthritis, and decline in ADLs, and stated there was no deviation from the care plan and no abuse, mistreatment, or neglect. However, there was no documented evidence in the investigation identifying who provided what care, when it was provided, or how many staff were involved in transfers or other care around the time of the injury to verify that the care plan, including two-person assist for transfers, was followed. The resident’s representative reported being informed only that the resident had a dislocated hip and not how it occurred. The Assistant DON later stated they relied on CNA interviews to determine the care plan was followed but could not explain why this was not documented in the written interviews or statements.
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