Failure to Conduct Thorough Abuse Investigation and Maintain Documentation
Penalty
Summary
The facility failed to maintain adequate documentation and conduct a complete and thorough investigation into an alleged abuse incident involving a resident with significant cognitive impairment and a diagnosis of dementia with psychotic disturbances. The incident in question involved a Certified Nursing Assistant (CNA) entering the resident's room, after which the resident fell to the floor. Statements from staff indicated that the CNA was attempting to enter the room to check on the resident's roommate, and the resident, who was blocking the door, lost balance and fell. The facility submitted a Facility Reported Event (FRE) to the Department of Health, but the investigation documentation was incomplete. Upon review, it was found that the facility did not identify or interview all potential witnesses, including the resident's roommates, despite statements indicating that at least one roommate was present during the incident. The Licensed Nurse Practitioner Unit Manager (LPN/UM) and the Director of Nursing (DON) both acknowledged that the investigation did not confirm who was present in the room at the time of the incident, nor did it include attempts to interview the roommates. Additionally, the DON confirmed that the care plan was not updated to reflect the allegation, and there was uncertainty about whether available security camera footage was reviewed as part of the investigation. The facility's own policies require that all involved persons, including the alleged victim, perpetrator, witnesses, and others with knowledge of the incident, be identified and interviewed. The policies also specify that the investigator should review completed documentation forms and interview roommates, family members, and visitors. The failure to follow these procedures resulted in an incomplete investigation and insufficient documentation regarding the alleged abuse incident.