F0609

D

Failure to Report Alleged Neglect After Improper Transfer Resulting in Femur Fracture

Desoto, Texas Survey Completed on 02-13-2026

Penalty

Fine: $24,845

Summary

The deficiency involves the facility’s failure to immediately report an allegation of neglect related to a serious injury sustained by a resident during a transfer, as required by regulation and by the facility’s own abuse/neglect policy. The resident was an older female with a history of stroke and end-stage renal disease, with moderately impaired cognition (BIMS score of 10) but no diagnosis of dementia or Alzheimer’s disease, and no documented inattention, disorganized thinking, altered level of consciousness, or behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair for mobility, did not attempt to stand due to medical/safety concerns, and required substantial/maximal assistance. The care plan specified that all transfers were to be done with a mechanical Hoyer lift and two or more staff due to impaired mobility.

On the day of the incident, the resident was transferred from her bed to her wheelchair at the facility prior to going to dialysis. The resident later consistently reported to multiple individuals that facility aides had manually transferred her instead of using the Hoyer lift, and that her left leg became twisted between a staff member’s legs during the transfer, causing immediate severe pain. She stated she told staff at the time, saying she thought they had broken her leg, but she was nonetheless placed in the wheelchair, transported by van, and sent to dialysis. At the dialysis center, multiple dialysis staff (RN, tech, nurse manager, and case manager) observed the resident crying in severe pain, unable to move her leg, and still sitting in her wheelchair with a Hoyer sling under her. The resident told them that nursing home staff had twisted her leg during the transfer to the wheelchair and that she had reported her pain to facility staff before being sent to dialysis. Dialysis staff did not transfer her to a dialysis chair due to her pain and arranged for EMS transport to the hospital.

Hospital records documented an acute comminuted fracture of the distal left femur, with the admission assessment noting that the patient’s leg had twisted during a transfer and that she had not fallen. Facility nursing notes show that the DON and LVN C were informed by hospital staff that the resident had a femur fracture and that the injury was reported as occurring during transfer at the dialysis center. The DON later documented a late entry describing a call from the dialysis RN about the resident’s complaints of leg pain and transfer to the hospital. Interviews with facility staff revealed that the resident was known to require a Hoyer lift for all transfers, that the Hoyer lift was reportedly broken that day, and that multiple CNAs manually transferred the resident using a sling and/or drawsheet. One CNA acknowledged assisting with the transfer and hearing the resident complain of leg pain afterward but did not report this to a nurse, assuming the primary aides would do so. Other CNAs gave conflicting or limited recollections of the transfer. Despite the resident’s repeated statements to dialysis staff and to her family that the injury occurred during a manual transfer at the facility, the Administrator stated the incident was not reportable because it was believed to have occurred at the dialysis center, and the facility did not report the allegation of neglect to the State Survey Agency as required by policy and regulation.

The facility’s written policy on Abuse, Neglect, and Exploitation required that all staff ensure alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property are reported to the Administrator (Abuse Coordinator), that the Abuse Coordinator initiate an investigation, and that reportable allegations be reported to the State Regulatory Agency. The report shows that the DON was informed of the resident’s severe leg pain and subsequent hospital transfer, and that the resident’s statements to dialysis staff implicated facility staff in twisting her leg during transfer. However, the DON did not contact the dialysis center to clarify events, relied on staff statements that “nothing happened,” and concluded there was no incident at the facility. The Administrator similarly concluded the event was not reportable because they believed it occurred at the dialysis center. As a result, the allegation of neglect—specifically, failure to follow the resident’s care plan requiring Hoyer lift transfers and the resident’s report that staff twisted her leg during a manual transfer—was not reported to the State Survey Agency within the required timeframe, constituting the cited deficiency.