Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to thoroughly investigate multiple alleged abuse incidents and unexplained injuries among residents. In one case, a resident was found with bruises of unknown origin on her foot, thigh, and calf, but there was no clear documentation in the medical record describing the bruises or their causes. Staff acknowledged that no further investigation was conducted beyond noting that the resident bruised easily, and no interventions or root cause analysis were completed. Additionally, several resident-to-resident altercations were not adequately investigated. These included incidents where one resident slapped, punched, or choked other residents, and another incident where a resident sprayed alcohol and sanitizer on another's face. The facility's documentation did not include interviews with involved parties, root cause analysis, or implementation of interventions to prevent recurrence. Progress notes often lacked details about the events, contributing factors, or steps taken to protect residents. Staff interviews revealed that the facility relied solely on event reports and risk management forms for investigations, with no further investigative actions taken.