F0610

D

Failure to Thoroughly Investigate Alleged Neglect After Resident Sustained Femur Fracture

Desoto, Texas Survey Completed on 02-13-2026

Penalty

Fine: $24,845

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident’s left distal femur fracture and to have evidence that all alleged violations of abuse, neglect, exploitation, misappropriation, and mistreatment, including injuries of unknown origin, were fully investigated. The resident was an elderly female with a history of stroke and end-stage renal disease, moderately impaired cognition (BIMS 10), no dementia diagnosis, and no documented behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair, did not attempt to stand due to medical/safety concerns, and required mechanical (Hoyer) lift transfers with assistance from two or more staff. On the date of the incident, she was sent to dialysis by third‑party transport and later diagnosed in the hospital with an acute comminuted closed fracture of the distal left femur, with hospital documentation stating that her leg was twisted during a transfer to the dialysis chair and that there had been no fall.

Multiple accounts from the resident and dialysis staff indicated that the resident consistently reported that her leg was twisted and injured during a transfer performed by facility staff from her bed to her wheelchair, and that she normally used a Hoyer lift but was instead manually lifted. The resident told surveyors that several staff, including a chubby female aide and a tall bald male aide, transferred her by hand rather than using the Hoyer lift, and that during the transfer her left leg went between the male aide’s legs and twisted, causing immediate severe pain. She stated she told staff at the facility that she thought they had broken her leg, but she was still placed in her wheelchair and transported to dialysis. At the dialysis center, the resident arrived in severe pain, crying, with a Hoyer sling still under her, and repeatedly told the dialysis RN, dialysis tech, and dialysis nurse manager that nursing home aides had twisted her leg during the transfer to the wheelchair and that she had reported pain to facility staff before being sent to dialysis.

Dialysis documentation and staff interviews corroborated that the resident arrived already in severe pain, was never transferred out of her wheelchair into a dialysis chair due to pain, and that she requested to be sent to the hospital. The dialysis RN and dialysis tech both reported that the resident, who was normally calm, pleasant, and cognitively appropriate during treatments, stated that facility staff had twisted her leg during transfer. The dialysis RN reported telling the DON that the resident said the injury occurred at the facility, and the dialysis nurse manager stated that at no time did dialysis staff tell the facility that the incident occurred at the dialysis center. Within the facility, the DON documented that a hospital nurse had said the injury occurred at dialysis and later stated she saw no reason to call the dialysis center to clarify events, did not interview CNA B at the time, and only noted that she had written staff statements “on a notepad somewhere,” with no evidence of a complete investigation. The Administrator stated the incident was not reportable because it happened at the dialysis center. Interviews with facility staff were inconsistent: one LVN did not ask the resident what happened when she returned, the ADON never spoke with the resident about the transfer, CNA B admitted assisting with a manual transfer using a sling and drawsheet because the Hoyer lift was allegedly broken and the resident was late for dialysis, and other CNAs either denied or could not recall the described transfer. Collectively, these actions and omissions demonstrate that the facility did not conduct and document a thorough investigation of the resident’s allegation of neglect and injury as required by its abuse/neglect policy.