Failure to Promptly Investigate Fall and Rule Out Neglect After Resident Rolled From Bed
Penalty
Summary
The deficiency involves the facility’s failure to promptly conduct a thorough investigation into a fall incident to rule out neglect and to complete and submit the investigation results to the State Survey Agency within five working days. Facility policies on Abuse and Neglect and on Reporting and Investigating Abuse, Neglect, Exploitation or Misappropriation require that all reports of possible abuse, neglect, and injuries of unknown origin be thoroughly investigated, documented, and reported to appropriate agencies. Resident R11 had diagnoses including Alzheimer’s dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right ORIF, and the most recent MDS showed the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning in bed. Multiple staff (NAs and an LPN) confirmed that substantial/maximal assistance meant two staff were required to perform the task. Clinical record review showed an order for bilateral enabler bars for positioning. A progress note documented that at 5:10 a.m. the nurse was called to the resident’s room and found the resident on the floor on her left side. Facility documentation indicated that a single NA entered the room alone to provide incontinence care, turned the resident onto her side, noted a bowel movement, and then left the resident on her side while going into the bathroom to wet a towel, during which time the resident rolled out of bed. The documentation did not indicate whether the enabler bar was in use at the time of the fall, nor did the facility-provided documentation show that the facility ensured the resident was protected from neglect while the physician was called and X-rays were ordered after the resident complained of pain. In an interview, the Nursing Home Administrator and DON confirmed the facility failed to promptly conduct a thorough investigation to rule out neglect and to submit the completed investigation results to the State Survey Agency within the required timeframe.
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