Failure to Conduct Thorough Abuse Investigations and Update Care Plans
Penalty
Summary
The facility failed to conduct thorough investigations and implement corrective actions to prevent recurrence of incidents involving alleged abuse and resident-to-resident altercations. For one resident with diagnoses including anxiety disorder, hemiplegia, hemiparesis, and dementia, the investigative summary did not identify when the alleged incident occurred. Additionally, interviews with several residents regarding safety concerns were not conducted correctly, and follow-up on their expressed concerns was inadequately documented. Some residents with severe cognitive impairment were inappropriately interviewed instead of their representatives, contrary to the facility's stated process. In another incident involving two residents, the investigation documented that one resident attempted to push another back to their room, leading to a physical altercation where one resident scratched and hit the other's arms, resulting in visible bruising. The investigation summary and care plans for both residents did not include any new or revised interventions to prevent recurrence of such incidents. Staff interviews confirmed that the only immediate action taken was to separate the residents, and there was no documentation of further corrective actions or care plan updates addressing the behaviors or protection for the involved residents. Facility staff, including the DON, RN Unit Manager, and Administrator, acknowledged gaps in the investigation process, such as lack of documentation regarding corrective actions, failure to update care plans with new interventions, and improper interview procedures for residents with cognitive impairment. The facility's policies required thorough investigation, identification of the incident's specifics, and care plan revisions to minimize recurrence, but these steps were not consistently followed in the reviewed cases.