Failure to Prevent Injury of Unknown Origin During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to prevent an injury of unknown origin and to ensure adequate supervision and accident hazard prevention for a cognitively impaired resident who sustained a right humerus fracture during care. The resident had Alzheimer’s disease, dementia, kidney disease, anxiety, and depression, was severely cognitively impaired, and was dependent for dressing, bed mobility, toileting, transfers, and largely for eating. Prior assessments and therapy records showed no documented contractures and upper extremity range of motion within normal limits, with the resident able to assist with feeding when items were placed in the hand. The resident was not on pain medication prior to the incident and had no documented pain on the most recent MDS. On the night and early morning in question, staff working the night shift reported no falls or incidents and stated the resident slept through the night without signs of distress. At approximately 5:00–5:15 a.m., a CNA entered the room to provide morning care and dress the resident, who was scheduled to be gotten up and dressed on the midnight shift. The CNA reported the resident was wearing a pull-over pajama top and was changed into another pull-over shirt. During dressing, the CNA noted the resident’s right arm appeared swollen and limp, and that when the resident attempted to help push the right arm through the sleeve, the resident expressed pain and the arm became limp. The CNA acknowledged that the resident was wincing, waving for care to stop, and more verbal than usual, but the CNA continued dressing instead of stopping care, later stating they should have stopped when resistance and increased pain were observed. Subsequent nursing assessment documented that the resident’s upper arm was swollen, abnormal in appearance, and misaligned at the elbow joint, suspicious for a fracture, with pain on minimal movement. The resident was sent to the ER, where imaging showed a displaced, angulated, spiral fracture of the distal humerus, described as atypical and typically resulting from significant trauma, a fall, or a hard twisting motion. Hospital and orthopedic records characterized the injury as an acute, unstable fracture, presumed to be from an unwitnessed fall or twisting trauma, while the facility’s internal investigation concluded the exact cause was unknown and did not substantiate abuse or neglect. The DON, who led the investigation, did not obtain a witness statement from the day-shift LPN who had cared for the resident before the transfer, and the medical record lacked a complete nursing assessment, pain assessment, change-of-condition assessment, and transfer form at the time of the resident’s transfer. The facility’s Incidents and Accidents policy addressed documentation and reporting of injuries of unknown origin but did not address prevention of such injuries.
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