Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain complete records for abuse allegations involving three residents. In one incident, two residents with cognitive impairments were involved in an altercation in the dining room, where one resident pushed another's wheelchair. Although staff separated the residents and initiated an investigation, the incident file lacked documentation of resident interviews and did not include statements from other residents to determine if there were additional concerns. Furthermore, the electronic health records for both residents did not contain any documentation of the incident. In another case, a resident with severe dementia reportedly sustained a skin tear to the right forearm after contact with a CNA. The CNA was suspended pending investigation, but the facility's documentation was incomplete. There was no skin assessment performed on the date of the incident, and subsequent skin check forms and nurse progress notes did not document the injury. The investigation file included an undated statement from the CNA and a resident interview, but lacked individual, signed, and dated statements from all staff present at the time of the incident. Additionally, the facility could not locate a statement from the nurse on duty during the incident. The facility's policy required obtaining statements from all involved parties and documenting facts and findings in each resident's medical record. However, in both incidents, the required documentation was missing or incomplete, including resident and staff statements, and proper recording of the incidents in the residents' health records. These deficiencies were confirmed through record review and interviews with the Executive Director and Regional Director of Clinical Operations.