Failure to Thoroughly Investigate Injuries of Unknown Source and Abuse Allegations
Penalty
Summary
The facility failed to ensure that injuries of unknown source and abuse allegations were thoroughly investigated for four out of five residents reviewed. According to the facility's own policy and state guidelines, all substantial injuries of unknown source, as well as all alleged incidents of abuse, neglect, or mistreatment, must be thoroughly investigated and documented. However, the records showed that investigations were either incomplete, lacked documentation, or did not include required interviews and conclusions to rule out abuse. For one resident, an allegation of rough treatment by staff was reported, but there was no initial written documentation of an investigation, and the investigation report was only completed after surveyor inquiry. Another resident was found with a fractured ankle of unknown origin, but the investigation did not include interviews with other residents or a documented conclusion ruling out abuse. A third resident was discovered with significant bruising on the torso, but the investigation lacked staff and resident interviews and did not document a conclusion. The fourth resident, who had cognitive deficits, was found with a dislocated shoulder and fractured arm, but again, the investigation did not include interviews or a documented conclusion regarding abuse. Staff interviews confirmed that the required investigative steps, such as interviewing witnesses or other residents and documenting conclusions, were not consistently followed. In several cases, staff acknowledged that investigations were incomplete or that documentation was missing. The lack of thorough investigations and documentation for injuries of unknown source and abuse allegations was observed across multiple incidents and residents.