Failure to Conduct Thorough Investigations into Abuse, Neglect, and Significant Injury
Penalty
Summary
The facility failed to implement its abuse prohibition policy for two residents by not conducting thorough investigations into incidents of abuse, neglect, and significant injury. For one resident, after a fall resulting in a broken arm and hip, the facility's investigation did not include statements from all relevant staff, such as those who delivered and picked up the resident's lunch, the nursing assistant assigned to the resident, or the student who found the resident. The investigation also failed to address the period between the last staff contact and the discovery of the fall, and did not consider whether the resident received lunch or if pain medication was effective. Additionally, the resident was not receiving oxygen at the physician-ordered rate at the time of the fall, and the incident was not reported in the abuse reporting logs as required for substantial injury related to a fall. In the case of the same resident's unexpected death, the facility did not thoroughly investigate the possibility of choking, despite multiple indications that choking may have been involved. Staff interviews and documentation revealed inconsistencies regarding the location of the meal tray and the events leading up to the resident being found unresponsive. The police report and statements from the resident's representative indicated that the resident had a history of choking and that food was found in the airway during the autopsy. The facility's investigation did not include all relevant witness statements or consider the choking hazard, even though the death certificate listed choking on a food bolus as the cause of death. For another resident with severely impaired vision and a history of falls, the facility's investigation into an unwitnessed fall was incomplete. The resident, who required extensive assistance and one-on-one staff support for meals, was found on the floor after not being seen by staff for over two hours. The investigation did not address why the resident was left unattended for such a period or include statements from all staff involved in the resident's care. The facility's actions did not align with its own policies for investigating abuse, neglect, and significant injuries, as required by regulation.