Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation in response to a potential allegation of abuse involving a resident with significant medical conditions, including osteoporosis, hemiplegia, and vascular dementia. The incident involved the discovery of discolored (yellow) areas on the resident's right knee and left ankle, which were reported by the resident's representative. The representative expressed concerns that improper positioning by a CNA during a shower may have caused the bruising and noted discomfort and unusual positioning of the resident after the bath. Despite facility policy requiring a comprehensive investigation of injuries of unknown origin, including interviews with other residents cared for by the implicated staff member, the facility did not interview other residents who had been under the care of the same CNA. The Director of Nursing confirmed that such interviews were not conducted, even though it was acknowledged that this step should have been part of the investigation process. The deficiency was identified through interviews and record review, which showed that the investigation was incomplete according to facility policy.