Failure to Investigate Injury of Unknown Origin Due to Misinterpretation of CPS Involvement
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an injury of unknown origin for a resident with cerebral palsy who was admitted with an abdominal bruise. The facility's policy required the QAPI Manager or designee to initiate an investigation for any allegation of abuse, neglect, or misappropriation, and to take immediate action to ensure resident safety. However, there was no documented evidence in the resident's medical record or in the facility's Final Report/5 Day Follow Up that a full internal investigation was initiated regarding the abdominal bruise. The facility paused interviews and other investigative steps, citing their interpretation of state law and guidance from their experience as a childcare agency, believing that interviewing during an active Child Protective Services (CPS) investigation would be considered obstructive. Despite this, the CPS Case Manager clarified that CPS never advised the facility to halt its internal investigation and that most facilities begin their own investigations immediately. Facility leadership, including the QAPI Manager, DON, and Administrator, confirmed that their practice was to stop interviews and internal investigation processes when CPS was involved, based on their understanding of regulatory requirements. As a result, necessary interviews and investigative actions were not completed, and the incident was not discussed in the QAPI meeting. The lack of a thorough internal investigation meant the facility did not fully determine the cause of the injury or whether staff had followed policies and procedures.