Failure to Thoroughly Investigate and Timely Report Alleged Neglect and Injury Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report two separate incidents involving allegations of neglect and injury of unknown origin for two residents. For one resident with severe cognitive impairment and multiple diagnoses including dementia, Alzheimer's disease, and a history of falls, an incident involving injury of unknown origin was reported. However, the investigation lacked documented interviews with the RN and MA who were present at the time of the incident, and the findings were not submitted to the state agency within five working days. Similarly, for another resident with intact cognition and multiple chronic conditions, an allegation of neglect was reported, but there were no documented interviews with the CNAs involved, and the findings were also not submitted within the required timeframe. Record reviews revealed that the facility's investigation reports and self-reporting checklists indicated interviews were either not completed or not documented, despite being checked off as done. The administrator stated that interviews had been conducted and were either in the binder or her office, but only one staff interview was found, and the remaining interviews were not provided to the surveyor upon request. The facility's policy requires a thorough investigation and timely reporting to the state agency, but these steps were not followed for the incidents involving both residents.