Failure to Thoroughly Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate two separate incidents involving alleged abuse and injury of unknown origin. In the first case, a resident with intellectual disabilities and physical impairments was found with new bruising around the right upper eyelid. The facility's investigation concluded the injury was accidental, based on the resident's nonverbal cues, but review of staff interviews revealed inconsistencies. Multiple staff assigned to the resident during the relevant period denied caring for the resident, despite schedule records indicating otherwise. Additionally, the unit manager interviewed herself as part of the investigation, and there was no clear process for verifying the accuracy of staff statements. In the second incident, a resident-to-resident altercation resulted in one resident sustaining a facial scratch and being sent to the emergency room. The facility's investigation lacked documentation of which staff first responded to the incident, and all witness statements indicated that no staff were present during the altercation. The statements also contained conflicting dates, and there was no documentation from the staff who heard the initial noise or separated the residents. Furthermore, abuse questionnaire forms used in the investigation did not include resident names or the names of interviewers, and skin assessment forms were incomplete, missing dates and staff identifiers. The scratch sustained by the resident was not documented on the skin assessment forms, and the medical record lacked details on the size and depth of the wound. Both incidents demonstrate failures in the facility's investigative process, including incomplete and inaccurate documentation, lack of thorough staff interviews, and insufficient record-keeping regarding resident assessments and incident response. These deficiencies were acknowledged by the DON during discussions with surveyors.