Incomplete Investigation of Incontinence Care Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an incident involving incontinence care for a resident. The resident, who was admitted with a BIMS score of 8 and diagnoses including Alzheimer's Disease, encephalopathy, Parkinson's disease, and angina, was found with wet sheets and stated he did not know when he was last changed. The nurse manager discovered the situation after responding to the resident's call bell and noted darker stains on the sheets. The resident's roommate confirmed that he was changed but could not recall the time. The investigation into the incident was incomplete, as it only included a statement from one nurse and lacked witness statements from other staff and residents. Interviews with staff revealed that a nurse aide failed to complete the required two-hour round and check and change for the resident. The Director of Nursing confirmed the investigation's incompleteness due to missing witness statements.
Plan Of Correction
A - Employee E14 was terminated following incident. Unable to complete investigation further at this time due to time lapse since incident. B - All allegations of abuse or neglect in last 30 days reviewed to ensure completion of investigation. C - Previous DON and NHA educated on Investigation process with completion of investigation including witness statements from all possible witnesses. Current DON and NHA are aware of the process for investigation. D - Weekly x 4 then monthly x 2 audits by DON or designee of abuse and neglect investigations to ensure completeness of investigation. Results discussed during QAPI meetings.