Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents involving potential abuse, neglect, and injuries of unknown origin for several residents. In two separate member-to-member altercations, the facility did not conduct interviews with other residents who may have witnessed the events, nor did they document the root cause or specific interventions for the individuals involved. In one incident, a resident reported being punched, but the facility did not investigate this claim further, despite a CNA's statement indicating possible physical contact. In another case, an allegation of abuse was reported to the State Survey Agency, but the facility did not interview other residents on the same unit to determine if there were additional concerns. The Director of Social Services acknowledged that resident interviews are typically part of the process but could not confirm that they were completed in this instance. Upon review, no resident interviews were found in the facility's documentation for this abuse allegation. Additionally, the facility did not complete a thorough investigation into an injury of unknown origin involving a resident who developed a right clavicle fracture. Multiple witness statements indicated the resident had been experiencing right shoulder pain for several days prior to the discovery of the fracture, but there was no evidence that these statements were followed up on to determine the cause of the injury or to rule out abuse or neglect. The lack of follow-up on these statements and the absence of further investigation into the timeline of the injury contributed to the deficiency.