Failure to Thoroughly Investigate Allegation of Potential Abuse
Penalty
Summary
The facility failed to ensure that an allegation of potential abuse involving a resident with severe cognitive impairment was thoroughly investigated, as required by its own policies. The resident, who had diagnoses including chronic pulmonary disease, osteoporosis, dementia, and diabetes, was assessed to have a severely impaired mental status. After the resident complained of leg and foot pain, a mobile x-ray revealed acute fractures, and the resident was sent to the emergency room. The facility's investigation into the incident was initiated only after the x-ray results were known, and focused on reviewing the resident's electronic medical record and obtaining statements from staff on the shift when the pain was reported. However, the investigation did not include written statements from staff on previous shifts, except for a verbal interview with a CNA who worked on an earlier date when the resident was noted to be restless. The Director of Nursing acknowledged that many staff interviews were conducted verbally and not documented in writing. The investigation summary was compiled by the team, but lacked comprehensive written documentation from all potentially involved staff, as required by facility policy. This incomplete investigation process resulted in a failure to thoroughly address the allegation of potential abuse.