Failure to Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate incidents of potential abuse and injuries of unknown origin for two residents. In the first case, a resident with severe protein calorie malnutrition, altered mental status, COPD, and weakness was found to have a new skin tear on the lower back during wound rounds. There was no documentation in the medical record regarding how or when the skin tear occurred, and no Self-Reported Incident (SRI) was completed. Interviews with the ADON, DON, and Regional Director of Clinical Services confirmed that no investigation was initiated to determine the cause of the injury, despite facility policy requiring such action for unexplained injuries. In the second case, a resident with CHF, anxiety disorder, and uropathy, who was also on hospice care, was found to have been tied to a wheelchair with a sheet by an LPN in an attempt to prevent the resident from standing unassisted or falling. The incident was reported by hospice staff, and an SRI was initiated. However, the facility's investigation was incomplete, as it did not include statements or notes from hospice staff who witnessed the event. The investigation file only contained statements from facility staff, and the final SRI was submitted before all relevant information was gathered. The DON later acknowledged that hospice staff statements were not included in the investigation, and the Regional Director of Clinical Services was unaware of all the information regarding the restraint incident. Facility policy requires that all unexplained injuries and allegations of abuse, neglect, or misappropriation be thoroughly investigated, including interviewing all witnesses and obtaining relevant documentation. In both cases, the facility did not follow its own protocols, resulting in incomplete investigations and a failure to respond appropriately to alleged violations.