Failure to Thoroughly Investigate and Document Resident Shoulder Fracture Incident
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation into a resident accident with injury, specifically a displaced scapular fracture, and to adequately document the circumstances of the incident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, sepsis, heart failure, heart disease, a displaced scapula fracture, cognitive communication deficit, and muscle weakness. An MDS assessment showed moderately impaired cognition and a need for supervision and touching assistance, and the care plan identified the resident as at risk for falls with interventions such as anticipating needs, ensuring call light access, appropriate footwear, and PT evaluation. Occupational therapy documented that the resident required contact guard assistance for toileting transfers and had requested a higher toilet. Over several days, progress notes and therapy notes documented new and increasing right shoulder and upper arm pain, with pain scores ranging from two to eight out of ten, interfering with therapy. On one date, the resident complained of right shoulder pain, the NP was notified, and a stat x-ray of the right shoulder was ordered along with an ice pack and a lidocaine 4% patch. The radiology report showed a displaced fracture of the scapula with degenerative changes, and the result was reviewed by the medical provider. An occupational therapy note recorded that the family requested a bedside commode over the toilet due to the resident recently injuring her right shoulder during a transfer. A risk assessment documented that the resident reported walking into a door post while going into the bathroom, with a pain level of six, but the assessment was marked privileged and confidential, not part of the medical record, and did not include follow-up on the injury, the x-ray results, the timing of the injury, or whether staff were assisting at the time. The medical record, including progress notes, contained no details on how the fracture occurred, and the incident/accident log had no entry for any fall or injury for this resident. The NP note stated the resident ran into a door jamb two days prior, but there was no corroborating detail in the record. Interviews with nursing and CNA staff who worked with the resident during the relevant period yielded no recollection of the resident or the incident. The resident’s family member reported that the resident fractured her shoulder after a toilet transfer with staff assistance and that both the resident and family informed management, who allegedly told them the resident had just bumped into the wall. The DON and Regional Nurse stated the resident was alert and oriented, referenced unnamed staff who said the resident bumped into the wall, and asserted it was not an unknown injury, but they could not state whether staff were present when the injury occurred, confirmed the event was not on the incident log, and acknowledged that staff statements were not obtained and there was no evidence in the medical record related to the cause of the fall or explanation for the discrepancy between the family’s account and facility documentation.
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