Incomplete Investigation and Documentation of Reported Incidents
Penalty
Summary
The facility failed to conduct and document complete investigations for multiple reported incidents involving residents and staff. Specifically, for an altercation between two residents in the dining room, the facility's documentation was limited to a single paragraph with no supporting evidence, such as interviews with the involved residents, staff, or witnesses. There were also no documented interventions or analysis to prevent recurrence. Additionally, the findings submitted to the State Survey Agency for this incident were inaccurate, referencing unrelated individuals and omitting the actual residents involved. In another incident involving an allegation of staff-to-resident verbal abuse, the facility's investigation was incomplete, lacking details on which residents were interviewed and their responses, as well as missing interviews with staff witnesses. The facility's own policies require thorough documentation, including interviews and written statements from all involved parties, but these procedures were not followed. Staff interviews revealed that documentation practices were inconsistent, with investigation notes being saved as findings without maintaining separate interview records or templates.