Failure to Investigate and Document Facility-Reported Events
Penalty
Summary
The facility failed to conduct thorough investigations and maintain comprehensive documentation following facility-reported events for three residents. In one case, a resident experienced an unwitnessed fall resulting in a significant injury, including a fracture of the S5 vertebrae, and was treated in the ER. Despite the seriousness of the injury and the resident being an unreliable reporter, the facility did not provide an investigation file when requested by surveyors. In another instance, a resident was involved in a resident-to-resident abuse incident where they were pinched by another resident, but again, no investigation file was available for review. Additionally, a third resident sustained an unwitnessed fall with injury and was treated in the ER. Documentation revealed that no investigation was conducted for this incident, as the DON was not present in the facility at the time and did not initiate an investigation upon return. The only documentation available for these events was the submission of the event to the State Survey Agency, with no formal investigation files maintained. Interviews with staff confirmed the lack of investigation and documentation for these incidents.