Failure to Investigate Alleged Abuse After Resident Sustained Rib Fractures During Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of possible abuse or mistreatment/neglect after a resident sustained new rib fractures associated with staff-assisted repositioning. The facility’s Abuse Prevention Program policy requires that all incidents be documented and that, for injuries not initially involving an allegation of abuse or neglect, an appointed investigator gather facts to determine whether the injury should be classified as an injury of unknown source. The policy further requires that the investigator, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident if interviewable, and other residents and employees who regularly interacted with the accused staff member, as well as review written statements and pertinent medical records. The resident at issue had multiple significant comorbidities, including a left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, sacral pressure ulcer, GERD, and a history of repeated falls. The resident’s care plan and physician orders specified that she required assistance of one staff member for ADLs, toileting, and bed mobility, with Q2–3 hour repositioning using a wedge from right side to back, and that she was fragile with multiple prior fractures. On the evening in question, while being repositioned in bed by a CNA, the resident complained of severe sharp, stabbing pain in the left ribs upon palpation. The CNA reported hearing a “crack” during repositioning and notified the nurse, who assessed the resident, administered PRN Tramadol, and subsequently sent the resident to the ER when pain remained uncontrolled. Hospital imaging identified suspected new fractures of the left 7th and 8th anterior ribs, along with old bilateral rib fractures and thoracic compression fractures. Following this event, the resident’s representative reported concerns to facility leadership that a CNA had entered the resident’s room agitated and aggressive about the use of the call light, and allegedly grabbed the resident around the torso and yanked her backward in bed, which the representative believed caused the rib fractures. The representative also reported to the State Survey agency that they were not aware of any action taken after the first incident and that the resident was transported to the hospital the next day for the second incident. Despite these concerns, the DON stated that she concluded no investigation was needed, relying on the physician’s opinion that the injury was of known source due to the resident’s comorbidities and fragility. The DON acknowledged speaking only with the CNA involved and not interviewing other staff on duty, other residents, or others who might have knowledge of the CNA’s demeanor or any issues between the CNA and the resident. The DON also stated she did not consider the representative’s questions and concerns as an allegation of abuse or neglect. As of survey exit, the facility was unable to provide additional information explaining why a thorough investigation into potential mistreatment during the repositioning was not conducted, contrary to the facility’s own abuse investigation procedures.
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