Failure to Conduct Thorough Investigations of Resident Injuries and Adverse Events
Penalty
Summary
The facility failed to ensure thorough investigations were conducted to rule out abuse or neglect for three residents who experienced significant adverse events. In the first case, a resident with cirrhosis, lymphedema, and mobility issues was found to have a new stage 3 pressure ulcer on the left hip during an outpatient physician visit. The wound was not present upon admission, and there was no documentation of the wound being measured or investigated upon the resident's return to the facility. Nursing staff and the DON confirmed that no incident report or investigation was completed, and the wound was not documented in the treatment administration records. In the second case, a severely cognitively impaired resident was found on the floor in a pool of blood after an unwitnessed fall, resulting in a head injury and emergency transfer to the hospital. The investigation provided by the facility was limited to a single report and statement, with no staff interviews or clear identification of the causal factor for the fall. The documentation did not address when the resident was last toileted or given fluids, despite the resident's dependence on staff for these needs. The DON was unable to provide further information regarding the root cause of the fall. The third case involved a resident with a history of falls and cognitive impairment who sustained two unwitnessed falls, one resulting in a skin tear in the bathroom with blood found at the bedside, and another skin tear during care by an agency CNA. Investigations into these incidents were incomplete, lacking statements from all relevant staff and failing to address key details such as the presence of blood by the bed and the circumstances of the skin tear during care. The DON and other facility leaders acknowledged that investigations did not fully determine the causal factors or rule out neglect, and the facility's own policy for incident investigation was not followed.