Failure to Investigate Resident Hip Dislocation of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin when a resident with a history of joint replacement surgery aftercare reported right hip pain. The resident, who had intact cognition and required substantial/maximal assistance with ADLs, complained of right hip pain on a Change of Condition form dated 11/21/2025, which documented intact skin with slight swelling. A radiology report the following day showed the resident had a femoral head arthroplasty with a superior lateral dislocation of the right hip. Despite this significant injury, the Assistant Director of Nursing stated that only the treatment nurse and one LVN were interviewed regarding the resident’s hip pain, and that the resident, CNAs, and the physical therapist who worked with the resident on the date of the complaint were not interviewed to obtain additional information about the pain and dislocation. The Administrator confirmed that the incident involving the hip dislocation was not investigated, even though the facility’s abuse prevention policy required that all allegations of abuse, neglect, misappropriation of resident property, or exploitation be promptly and thoroughly investigated by the Administrator or designee.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.