Failure to Conduct Thorough Abuse/Neglect Investigation for Resident Fracture
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of abuse or neglect involving a resident who sustained a fracture. The investigation was limited in scope, as statements were only collected from two staff members, and no other staff, residents, or resident representatives were interviewed. The investigation did not expand the time frame to include the period indicated by hospital providers, and there was no evidence that the facility considered whether other residents might have been affected. Additionally, no staff were removed from the floor during the investigation, and there was no documentation of a comprehensive review or reenactment results. Medical records indicated that the resident's fracture was not acute but partially healed, suggesting the injury occurred weeks prior to its discovery. The resident was non-ambulatory, non-verbal, and dependent on staff for all activities of daily living. There was no documentation in the resident's care plan or nursing notes indicating a history of the resident putting her legs over the side of the bed, which was suggested as a possible cause of injury by staff. Interviews with staff and medical professionals revealed skepticism about the proposed cause of injury and highlighted inconsistencies in the investigation process. The facility's policy required protection of residents during investigations and comprehensive documentation, including gathering written reports from all involved parties and witnesses. However, the investigation file lacked evidence of these required steps, including documentation of interviews, findings, and actions taken to protect other residents. The investigation into the injury of unknown origin was incomplete, and there was no evidence of an abuse or neglect investigation until after the initial review was finished.