Failure to Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to implement its own policies and procedures requiring thorough investigations of abuse, neglect, and misappropriation allegations for four residents. In multiple cases, the facility did not complete or retain required 5-day investigation reports, did not document interviews with staff or residents, and failed to update clinical records with relevant information about incidents. For example, one resident experienced an unwitnessed fall resulting in a hematoma, but the facility could not provide the mandated 5-day investigation report, and the resident's family reported not being notified of the incident on the day it occurred. Attempts to contact staff involved at the time were unsuccessful, and documentation was incomplete. Another resident reported rough treatment by a CNA, resulting in a bruise, but the facility's 5-day report was incomplete and lacked staff or resident interview accounts. There was also no documentation of disciplinary action taken against the staff member involved. Interviews with current staff revealed inconsistent practices regarding documentation and investigation, with some staff unaware of the incidents or unable to recall details. The facility's policies required interviews with witnesses, residents, and staff, as well as immediate family notification, but these steps were not consistently followed or documented. Additional deficiencies included a failure to investigate a resident's report of a missing wallet, which involved potential misappropriation of funds. The facility did not document interviews or complete a 5-day investigation report, and the administrator confirmed that such incidents are reportable and should be investigated with written records. In another case, a resident sustained a hip fracture after a fall, with conflicting documentation about whether a resident-to-resident altercation occurred. The incident report did not address the altercation as a probable cause, and required documentation and interviews were missing. Facility policies clearly outlined the steps for investigating and documenting such incidents, but these were not adhered to in the cases reviewed.