Failure to Complete Thorough Investigations for Self-Reported Incidents
Penalty
Summary
The facility failed to conduct thorough investigations for five self-reported incidents (SRIs) involving six residents. The review found that for each of these incidents, the facility did not obtain staff interviews or statements, did not conduct resident interviews, did not assess other residents with similar conditions, and did not provide staff education related to the incidents. These failures were confirmed by the Administrator, who acknowledged that these investigative steps were not completed as required by facility policy. The residents involved had a range of medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), cerebral vascular accident (CVA), systemic lupus, dementia, and vascular dementia. Some residents were cognitively intact, while others had cognitive impairment. The facility's policy on abuse, neglect, and exploitation requires immediate and thorough investigations, including interviews with all involved parties and complete documentation, but these procedures were not followed for the incidents reviewed.