Failure to Investigate and Report Incidents as Required
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents and submit the required five-day follow-up investigation reports to the State Agency for multiple residents. In several cases, documentation was missing regarding staff and resident interviews, as well as evidence of completed investigations. For example, incident records for one resident did not include documentation of staff interviews or submission of the five-day follow-up report. Another resident's incident file lacked documentation of both staff and resident interviews. Additionally, there was no documentation showing that staff had completed education on handling emergency situations for another resident's incident. Further review revealed that when residents reported experiences of verbal threats or derogatory remarks from other residents, there was no documentation to demonstrate that these responses were investigated or that any follow-up actions were taken. In an incident involving resident-to-resident abuse, while the initial incident was reported to the appropriate agencies and immediate actions were taken, the required five-day follow-up report outlining the investigation, findings, and actions taken was not submitted. These deficiencies were confirmed through interviews with facility leadership and review of facility records.