Failure to Thoroughly Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate self-reported incidents (SRIs) involving two residents. For one resident with diagnoses including breast cancer, depressive disorder, and dysphagia, there were two separate SRIs: one involving a bruise of unknown origin on the thumb and another where the resident alleged a staff member held down her hand. In both cases, the investigation lacked written staff statements, resident interviews, and non-verbal resident skin assessments. The only documentation included was an undated staff education sign-in sheet with no presenter or topic listed. For another resident with metabolic encephalopathy, repeated falls, sepsis, COPD, and hypertension, an SRI was filed after a family representative reported bruises of unknown origin on the resident's torso. The investigation documentation for this incident also lacked written staff and resident interviews, as well as non-verbal resident skin assessments. The Administrator and DON confirmed that the investigations did not show documented evidence of a thorough investigation as required by facility policy, which mandates interviews with residents, witnesses, and staff, as well as assessments when injuries of unknown source are reported.