Failure to Conduct Thorough Investigations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations and incidents involving potential abuse and injuries of unknown origin among residents. In one incident, a resident was found by an LPN in another resident's room, naked from the waist down and caressing the other resident's hip and thigh. The investigation did not determine when the resident entered the room, the duration of the encounter, or provide detailed accounts of what was witnessed. The facility also failed to collect comprehensive statements from all staff present, did not clarify the sequence of events regarding the separation and monitoring of the residents, and did not preserve or document video footage from the night of the incident. The investigative file lacked sufficient detail and failed to address the resident's known behavioral history, and the conclusion was made without substantiating the allegation or fully exploring the extent and cause of the incident. In two additional cases, the facility did not thoroughly investigate injuries of unknown origin. One resident was found with a bruised and fractured finger, and another with a bruised, swollen, and fractured foot/ankle. In both cases, the facility's investigations did not include interviews with all staff who may have had knowledge of the incidents or who worked with the residents in the days prior to the injuries. There was also a lack of documentation regarding body assessments after the injuries were identified. In one case, the administrator was unaware of a note containing potentially important information, and there was no evidence that the results of the investigation were discussed with the resident's family. These failures affected three residents who were sampled for abuse. The facility's actions did not comply with its own policy, which required immediate and thorough investigations, identification and interviewing of all involved persons, and complete documentation. The lack of comprehensive investigations and documentation prevented the facility from determining the root causes of the incidents and from developing appropriate action plans to prevent recurrence.