Failure to Prevent Falls and Investigate Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to prevent accidents for three residents. For the first resident, who had traumatic subdural hemorrhage, dementia with mood disturbance, muscle weakness, and was care planned as dependent on two-person assistance for transfers, a CNA attempted a stand-pivot transfer alone. The resident fell, struck their head on the bedside table and garbage can, and sustained a forehead laceration requiring sutures and hospital evaluation. The CNA later stated they were not aware the resident required a two-person assist because they did not check the Kardex, despite the Kardex being accurate at the time and the resident’s care plan clearly indicating a two-person transfer requirement. For the second resident, who was severely cognitively impaired and had recently undergone eye surgery, staff discovered a bruise on the right hip and noted that the resident, who had previously been able to stand and ambulate for surgery, could no longer stand and complained of pain. An Accident and Incident report documented a purple bruise on the right hip and that the resident was unable to describe what happened. The x-ray later showed a displaced acute fracture of the right femoral neck. There was no documentation of how the injury occurred, no staff statements, and no facility investigation to determine the cause of the injury. The incident was not reported to the New York State Department of Health, and the Medical Director stated they had no idea what caused the incident and would have expected a more thorough investigation and look-back of staff who provided care. For the third resident, who had Alzheimer’s disease, severe cognitive impairment, used a wheelchair for mobility, and required assistance for transfers and bed mobility, staff identified a large purple bruise with swelling on the left lower leg. The resident showed mild discomfort on palpation and later complained of pain when the area was touched. The Accident and Incident report, completed by the Infection Control Nurse, concluded that the bruise resulted from bumping the Hoyer lift during transfer, but there were no supporting staff statements in the report. The DON later stated they did not know how the Infection Control Nurse reached that conclusion and that they were not made aware earlier. Subsequent evaluation in the emergency department revealed a fracture of the left tibia and fibula of unknown origin. Across these three cases, the facility did not ensure adherence to care plans, did not adequately investigate injuries of unknown origin, and did not ensure that the resident environment and transfer processes were free of accident hazards, resulting in actual harm to the residents.
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