ENGLEWOOD, CO- JULIA TEMPLE HEALTHCARE CENTER

Based on record review and interviews, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for one (#4) of three residents reviewed of six sample residents.
The facility identified a skin alteration (laceration) on the resident’s face on 4/28/21 and initiated an investigation. Approximately fifteen minutes later, the resident started complaining of left hip pain. The facility did not investigate the cause of the resident’s hip pain or identify the cause of the skin alteration to the resident’s face.

Due to the facility failures, the resident required hospitalization for a fracture of the left femoral neck (left hip) requiring surgical intervention and a one centimeter (cm) laceration to her left cheek (see hospital summarization, record review).

In addition, when the resident was readmitted from the hospital, the facility did not initiate interventions to prevent the resident from occurring further injury.

The 4/29/21 hospital summarization revealed the resident presented to the center on 4/29/21 after an unwitnessed fall at her living facility the previous evening. It indicated the resident had a left intertrochanteric femur fracture and a one centimeter (cm) laceration to her left cheek repaired with a liquid adhesive.

A 5/3/21 provider progress note revealed the resident had a suspected unwitnessed fall on 4/28/21 and was complaining of left hip pain and had a left facial laceration. X-rays, done at the facility, showed a non-displaced intertrochanteric hip fracture, so the resident was transferred to the hospital for evaluation. It indicated the resident underwent an IM nailing (a metal rod inserted into the inner part of the bone) of the left femur on 4/29/21 after receiving a left hip block for [MEDICATION(S)] in the emergency room .

The facility did not provide an investigation of the fracture of unknown origin. The facility did not determine the cause of the fracture or the laceration to the resident’s face. The facility did not implement interventions to prevent further injury to the resident immediately following the incident or when the resident returned from the hospital.

The director of nursing was interviewed on 5/20/21 at 3:14 p.m. She said the staff did not report the resident falling so she assumed the fracture was spontaneous because the resident had severe osteopenia (loss of bone mass). However, this diagnosis was not listed on the resident’s CPO or electronic medical record (EMR).

She said she had talked to the staff about the incident but did not document it. She did not feel the fracture needed to be investigated since the resident did not fall. The DON also stated that she had not read the hospital report sent back with the resident as she did not have time to read all reports sent back with each of the residents. This statement confirms the injuries of unknown origin were not investigated to rule out abuse (F610) or to determine the root cause and analysis.