Failure to Accurately Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to conduct an accurate and thorough investigation into an allegation of abuse involving a resident. According to the records, the resident called the police to report abuse after a nurse attempted to prevent him from leaving the facility late at night. The nurse involved was placed on administrative leave pending the outcome of the investigation. The facility's Five Day Follow-Up Report, which was submitted to the State Agency, included information that the resident was frequently outside the facility, had interactions involving suspected drug use, and had been sent to the emergency room for suspected overdoses. However, a review of the resident's electronic medical record did not show any documentation of these incidents, including suspected overdoses, administration of Narcan, or emergency room visits for overdose. During an interview, the Administrator who authored the Five Day Follow-Up Report admitted he could not verify that the resident had been sent to the emergency room for a suspected overdose and stated he may have confused this resident with another. This resulted in the submission of an inaccurate report to the State Agency, as the information provided did not match the resident's documented medical history. The lack of accurate documentation and investigation into the abuse allegation prevented the State Agency from appropriately reviewing the incident for further investigation.