Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain complete documentation in response to allegations of abuse for two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease and metabolic encephalopathy, was reported by a responsible representative at a dialysis center to have a bruise and pain on the left foot. Prior to dialysis, both a physician and a registered nurse assessed the resident and found no bruising or complaints of pain. However, after the report from the dialysis center, there was no evidence that the facility initiated or documented a full investigation into the injury, as required by protocol. The Director of Nursing confirmed that no investigation or follow-up with the dialysis center was conducted, and no incident or fall investigation was found for the date in question. In the second case, a resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease and bipolar disorder, was reported by a representative to have been hit by a staff member, resulting in a scratch and discoloration on the forehead. The resident was assessed, transferred to the hospital, and the incident was reported to the state health department. The facility initiated a 72-hour lookback investigation, suspended two CNAs pending investigation, and collected statements from some staff and residents. However, the investigation file was missing several required staff statements from the relevant shifts during the lookback period. The LNHA acknowledged that not all statements were obtained in writing, despite facility policy requiring thorough documentation and interviews with all involved persons. The facility's policy on abuse, neglect, and exploitation mandates a thorough investigation and complete documentation for all alleged violations. In both cases, the facility did not meet these requirements, as evidenced by the lack of a documented investigation for the first resident's injury and incomplete staff statements for the second resident's abuse allegation. These deficiencies were confirmed by interviews with facility leadership and review of facility records and policies.