Failure to Thoroughly Investigate Allegations of Misappropriation and Injury
Penalty
Summary
The facility failed to ensure that allegations of misappropriation of resident property and incidents resulting in injury were thoroughly investigated, as required by their own policies. In the case of one resident with intact cognition, the resident reported $173 missing from her lockbox, with the key found out of place after she returned from a shower. Although the incident was reported to the administrator and the police were notified, the facility's investigation was incomplete. Only one staff statement was documented, and there was no evidence of interviews with the resident's roommate or other potentially knowledgeable staff. The administrator admitted that not all interviews were documented and confirmed that the roommate was not interviewed, contrary to policy requirements for a thorough investigation. In another case, a resident with severe cognitive impairment experienced an unwitnessed fall in the dining room, resulting in a laceration to the back of the head and subsequent diagnosis of a cervical fracture after hospital transfer. Staff interviews revealed that the event was unwitnessed, and the resident was found on the floor with signs of seizure activity. However, the facility's incident report to the state agency inaccurately documented the event as a witnessed fall on a different date. The administrator acknowledged the discrepancy between the resident's record and the report submitted to the state agency and stated that a more thorough investigation would have been conducted if the event had been recognized as unwitnessed. In both cases, the facility did not follow its written procedures for investigations, which require identifying and interviewing all involved persons, focusing the investigation on determining the extent and cause of the incident, and providing complete documentation. The lack of thorough investigation and documentation had the potential to contribute to further misappropriation of property and inadequate response to incidents resulting in injury.