Failure to Thoroughly Investigate Alleged Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of injury of unknown origin and possible physical abuse involving one resident. According to the facility's policy, all accidents or incidents must be investigated and documented, including witness accounts, notification of family and physician, and detailed reporting. In this case, a registered nurse observed bruising on a resident's right hand and forearm, and upon questioning, the resident claimed to have been in a fight with two girls. An investigation was reportedly started immediately. However, the documentation and investigative process were incomplete. The five-day report submitted to the state did not include the names of staff involved, written statements from staff, or evidence that the attending physician was notified. The resident's responsible party was only notified after the investigation was completed. Additionally, the administrator confirmed that there was no incident report on file and that other residents were not interviewed as part of the investigation. These omissions were contrary to the facility's own policy and resulted in a deficient practice.