Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving potential abuse, neglect, or mistreatment, as required by its own policies and federal regulations. In the first incident, a resident with severe cognitive impairment and dysphagia was fed regular consistency chicken tenders instead of the prescribed mechanical soft, minced diet. This error occurred after a certified nurse aide intentionally swapped meal plates among three residents without verifying dietary restrictions, resulting in the resident choking and requiring emergency intervention. The facility's investigation did not determine where the incorrect food originated, nor did it include a review of the dietary plans or meal tickets for the other residents involved in the plate swap. Key staff, including the therapy director, nurse practitioner, and medical director, were unaware of the full extent of the incident, and the director of nursing acknowledged the investigation was incomplete. In the second incident, a resident with dementia and a history of behavioral symptoms was found to have a bruise of unknown origin below the right eye. Documentation showed that the discoloration was first noted as purpura by a registered nurse, but no provider assessment or investigation was initiated at that time. The facility's investigation began several days later, did not review all relevant progress notes, and failed to interview all staff assigned to the resident during the period when the injury could have occurred. Several staff members, including those who provided care during the relevant shifts, confirmed they were not interviewed as part of the investigation. Both the director of nursing and the administrator later acknowledged that the investigation was not thorough and did not follow the facility's established procedures for injuries of unknown origin. In both cases, the facility's failure to conduct comprehensive investigations meant that not all potential causes or responsible parties were identified, and the required steps to rule out abuse or neglect were not completed. The deficiencies were confirmed through staff interviews, record reviews, and direct admissions from facility leadership that the investigations were incomplete and did not meet policy or regulatory standards.