Failure to Document Abuse Investigation Interventions
Penalty
Summary
The facility failed to ensure that three Facility Reported Incidents (FRIs) involving allegations of abuse were thoroughly investigated for three residents. For each of these residents, the facility's final reports indicated that interventions such as alert charting and skin assessments were to be completed as part of the investigation process. However, upon review of the electronic medical records, there was no documentation found to support that these interventions were actually performed. Interviews with the Administrator confirmed that these interventions were considered part of the investigation, but the required documentation was not present in the residents' records. The residents involved had significant medical histories, including orthopedic aftercare, spinal fusion, hemiplegia following stroke, diabetes, hypertension, and foot drop. Despite the facility's policy requiring thorough investigation and documentation of all alleged abuse incidents, there was a lack of evidence that the specified interventions were carried out. This deficiency was identified through both record review and staff interviews, which consistently failed to produce documentation of the alert charting or skin assessments that were reported as completed in the FRIs.