F0610

D

Failure to Investigate Injury of Unknown Origin After Unwitnessed Fall and Hospital Transfer

Williamsburg, Virginia Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The facility failed to investigate an injury of unknown origin for one resident who required emergent hospital transfer. The resident was admitted with diagnoses including dementia and weakness. An Incident/Accident Report documented that the resident was found lying on the floor, complaining of right leg pain, and that the incident was unwitnessed. The Day Shift Supervisor reported being informed by the Social Services Director that the resident was discovered on the floor and stated she was responsible for follow-up investigation of incident/risk management reports. She interviewed the assigned nurse and two CNAs on the unit, all of whom stated they did not witness the fall.

No additional interviews were conducted to determine what led to the resident being found on the floor in pain and then emergently transferred to the hospital. The Executive Vice President/Chief Operating Officer was unable to provide credible evidence to surveyors that a thorough investigation had been completed or to explain the incident. The Chief Clinical Officer stated surveyors were not permitted to review incident/risk management reports, staff statements, or investigative documentation and also did not provide credible evidence that a thorough investigation had been completed. This was inconsistent with the facility’s own policy, which requires the Administrator to immediately begin an investigation of all injuries of unknown source, including interviewing the resident and all witnesses, expanding interviews to prior shifts if there are no direct witnesses, obtaining written statements, and reviewing medical reports and records, and to reach a conclusion regarding whether abuse occurred and the probable source of the injury.