Failure to Conduct Thorough Investigations of Abuse Allegation and Serious Injury
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving residents. In the first case, a resident was hospitalized with a rib fracture and pneumothorax after a fall, and reported to hospital staff that they had been pushed by an unknown person, constituting an abuse allegation. Although the facility initiated an abuse investigation upon the resident's return, there was no documentation of witness statements or interviews with staff and other residents. The DON was unable to provide these documents, stating that the investigation had been handled by former staff and that the necessary records could not be located. In the second incident, another resident complained of leg pain and swelling upon arrival at a dialysis center, stating they had been dropped at the facility. The dialysis nurse communicated this to the facility and documented the conversation, but the corresponding communication flow sheet later returned to the facility was missing the nurse's written notes and signature. The facility's incident report indicated the resident was injured during transport due to not being strapped in, resulting in a femur fracture. Despite this, there were no statements from the van driver, escort, resident, facility nurse, or geriatric nursing assistants involved in the incident, and the facility could not produce documentation of a thorough investigation. Both incidents demonstrate a lack of comprehensive documentation and investigative follow-through, as required when responding to allegations of abuse or serious injury. The absence of witness statements, staff interviews, and relevant communication records contributed to the facility's failure to appropriately respond to and investigate these significant events.