Failure to Thoroughly Investigate Unwitnessed Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation to rule out abuse or neglect as the cause of a resident’s fracture following an unwitnessed fall. The resident had dementia, was confused, exhibited wandering behaviors, had a history of falls, and required maximum assistance with dressing. The resident had physician orders and a care plan requiring hip savers to be worn at all times due to fall risk. On the day of the incident, the resident was found on the floor on his left side between two nightstands in another resident’s room, with an open area on the left side of the head, an abrasion on the left upper arm, a skin tear on the left elbow, and severe pain in the left hip and leg when the leg was straightened. The resident was sent to the hospital and diagnosed with a left hip fracture. The facility’s fall and abuse/neglect policies required immediate notification of the RN Supervisor, detailed documentation of fall circumstances, and a thorough investigation of any alleged violations, including identifying and interviewing all involved persons and witnesses. The facility’s investigation documented that the resident had an unwitnessed fall and indicated that hip savers were in place at the time of the fall. However, the RN who first assessed the resident and the RN Supervisor both observed and confirmed that the resident was not wearing hip savers at that time, and the RN reported this to the RN Supervisor. These observations and statements were not included in the written investigation, and the ADON and DON later confirmed they were not aware that the resident did not have hip savers on at the time of the fall. There was no documented evidence that the investigation incorporated these witness observations or fully explored the lack of hip savers as a potential factor, resulting in a failure to conduct a thorough investigation as required by facility policy and state regulations.
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