Failure to Thoroughly Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving residents. In the first case, a resident with multiple complex diagnoses, including carcinoma in situ of the esophagus, severe protein calorie malnutrition, vascular dementia, and an above-the-knee amputation, was involved in an incident of alleged verbal abuse by a CNA. The incident was witnessed by another CNA, who reported that the accused CNA became verbally aggressive, yelled, and threatened the resident and another individual. The witness reported the event to the Unit Manager Nurse (UMN) and submitted a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. Interviews confirmed that neither the DON nor the Administrator were aware of the incident, and the written report could not be located. The resident involved confirmed feeling threatened and described the event as verbal abuse. In the second case, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a significant injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple fractures that required surgery. The facility's investigation included a timeline, resident interview, and hospital paperwork, but the DON did not attempt to obtain a police report or further details about the motor vehicle accident, relying solely on the hospital's account. The investigation was not comprehensive, as it did not include efforts to gather all relevant information about the circumstances of the injury. The facility's policy requires that all allegations of abuse and injuries of unknown origin be thoroughly investigated, including interviews with all relevant parties and, when necessary, expansion of the investigation to include additional staff or shifts. In both incidents, the facility did not follow its own protocols for reporting and investigating, resulting in incomplete investigations and a failure to ensure that all aspects of the incidents were properly addressed.