Failure to Investigate Injury of Unknown Cause and Follow Care Plan for Stand Aid Use
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an incident involving an injury of unknown cause and to follow required assessment and reporting processes. A cognitively impaired resident with a BIMS score of 6/15 and a care plan identifying high fall risk, self-care deficits, frequent falls, weakness, and decreased mobility required assist of one with a stand aid for transfers and assist of two with a stand aid for toileting. On the date of the incident, a CNA used the stand aid alone to change the resident’s incontinence brief, contrary to the resident’s care plan and to later staff statements that two-person assist is required for toileting. During this toileting-related use of the stand aid, the resident’s legs became weak, the resident’s feet slipped off the stand aid platform, and the CNA lowered the resident to the floor. Another CNA entered the room after noticing the door was closed, observed the resident on the floor with the first CNA present, and reported that the first CNA told them not to get a nurse and that the resident did not need a blood pressure check. This second CNA stated they were unsure the incident would have been reported if they had not entered the room and that the first CNA was trying to move the resident before a nurse assessed the resident. The LPN who responded found the resident sitting upright on the floor, with no complaints of pain and stable vital signs, and completed an assessment only after the resident was assisted up with a Hoyer lift and three staff. The facility did not provide evidence that an RN completed an assessment after the LPN’s initial assessment, despite the DON’s stated expectation that an RN should assess the resident as soon as possible after an LPN assessment. The facility did not treat the event as an abuse allegation or as an injury of unknown cause requiring a thorough investigation. The DON acknowledged that the CNA did not follow the resident’s care plan, that other potentially affected residents and staff should have been interviewed, and that further investigation should have been completed. The NHA stated the incident was not investigated as an abuse allegation because they believed the CNA had followed the care plan, later acknowledging that the CNA had not followed the toileting portion of the care plan and that further interviews and education should have been completed. The facility did not complete staff education related to the incident at the time of the survey, and there was no evidence of comprehensive interviews with other staff or residents or of further investigation after the facility became aware that the resident had sustained a fracture.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.