Failure to Investigate and Document Alleged Abuse or Neglect Following Unwitnessed Falls
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for two residents who experienced unwitnessed falls with injuries. For one resident, who had diagnoses including acute respiratory failure, dementia, muscle wasting, and sepsis, there was no documented incident report or evidence of a thorough investigation following an unwitnessed fall that resulted in a laceration and swelling to the right eyebrow. The resident was found on the floor by staff, was confused, and unable to explain what happened. Despite the injury and the resident's cognitive impairment, there was no incident report submitted to the state agency, and no documentation of a post-fall interview or investigation was found in the medical record. Another resident, with diagnoses including heart failure, repeated falls, and severe cognitive impairment, also experienced an unwitnessed fall resulting in a hematoma and laceration to the face. The nursing staff documented the immediate care provided and notified the DON and physician, but again, there was no evidence of a facility incident report or state notification for this injury of unknown origin. The DON and ADM both stated that their protocol requires reporting and investigation of all unwitnessed falls with injury, but could not provide documentation or recall why these incidents were not reported as required. The DON also indicated that she does not keep documentation of post-fall interviews or chart them in the electronic medical record. Facility policies reviewed require immediate investigation and documentation of all alleged violations, including injuries of unknown source, and mandate reporting to the state agency within specified timeframes. Despite these policies, the facility did not follow its own procedures for reporting, investigating, and documenting the incidents involving the two residents. Staff interviews confirmed that required steps, such as completing incident reports and submitting state notifications, were not consistently performed, and there was a lack of thorough documentation regarding the investigation of these unwitnessed falls.