Failure to Thoroughly Investigate and Document Facility Reported Incidents
Penalty
Summary
The facility failed to fully investigate and document four Facility Reported Incidents (FRIs) involving resident injuries and concerns. In one case, a resident sustained a fracture, but the investigation did not include interviews with the injured resident, relevant staff, or resident representatives, nor was a root cause analysis documented. Another incident involved an unwitnessed fall resulting in a hospital visit; while the interdisciplinary team identified a root cause, there was no documentation of interviews with the resident or staff involved. In a third case, a family member expressed concern and requested hospital transfer for a resident, but the investigation only included a nurse interview and omitted interviews with the resident, family member, CNA, or other involved staff, and lacked a root cause analysis. The fourth incident involved a resident who fell in the facility's parking lot, was hospitalized, and later died; the investigation did not include interviews with the resident or key staff, and there was no documentation of potential root causes. The facility's policy required thorough investigation and documentation of incidents, including root cause analysis and interviews with witnesses and involved parties. However, the investigations reviewed were inconsistent and incomplete, lacking required interviews and documentation. Staff attributed these deficiencies to changes in upper management and increased workload, resulting in incomplete investigations for all four reviewed incidents.