Failure to Investigate Serious Injury Incidents
Penalty
Summary
The facility failed to thoroughly investigate two reported incidents of potential abuse, neglect, exploitation, or mistreatment involving sampled residents. For one resident, the facility reported to the State Survey Agency that the resident had an unwitnessed fall during the night, initially resulting in mild left hip pain, followed by subsequent weakness in the left leg. A left knee X-ray obtained several days later showed a fracture of the distal femoral metaphasis, yet the Administrator confirmed there was no investigation documentation for this incident. For another resident, the facility reported that the resident sustained a head injury during a hoyer lift transfer, and a change in neurological status was identified the following day. A head CT scan revealed a subdural hematoma, but the Administrator in Training stated he could not locate the five-day summary report or any investigation of the incident. He acknowledged that investigations into these incidents should have been completed to rule out neglect or abuse.
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