Failure to Conduct Thorough Investigations into Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations into alleged abuse or injuries of unknown origin for two residents. One resident, with a history of stroke and neurological disorder and moderate cognitive impairment, was found to have a right shoulder dislocation requiring surgery, as well as healing fractures of multiple right ribs. In both instances, the facility's investigations did not identify the source of the injuries, lacked interviews with the resident, staff who provided care, or other residents, and did not include a summary of the timeline of the injuries. One of the investigations was left blank, and there was no documentation of efforts to determine how the injuries occurred. Another resident, who had dementia and mood disturbances with moderate cognitive impairment, reported that a staff member made inappropriate comments about their body. The facility's investigation into this allegation did not include interviews with a sample of residents who had received care from the named staff member. The Director of Nursing acknowledged that staff and resident interviews should have been conducted as part of the investigations.