Failure to Thoroughly Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse for one resident. An alert and oriented resident with multiple diagnoses and complex medical needs was admitted following an acute hospitalization and later provided the Unit Manager with a handwritten note alleging that on the second day of admission the resident was “beaten up during bath time.” The note did not identify staff or the shift involved. Review of the investigation showed no documentation that the resident was interviewed about the allegation after staff became aware of it. The investigation file also contained an undated typed statement indicating that when social services went to visit the resident about an incident, the resident declined to talk and declined to write a statement, but the document did not identify the author, the social services staff involved, or the specific incident referenced. Further review of the abuse investigation revealed that no interviews were documented with other residents on the unit, despite the allegation of abuse. Instead, statements were obtained from resident representatives for three other residents who were documented as cognitively impaired and not interviewable, with no documentation explaining why residents themselves were not interviewed. Staff interview statements were only obtained from the nurse and GNA on the 7 AM–3 PM shift and the nurse and GNA on the 3 PM–11 PM shift for the date of the alleged incident. There was no documentation of interviews with the nurse and GNA assigned to the resident on the 11 PM–7 AM shift, and no written statement from the Unit Manager who originally received the handwritten abuse allegation from the resident. The deficiency also includes the facility’s failure to thoroughly investigate an injury of unknown source for another resident. This resident, admitted with multiple diagnoses, severe cognitive impairment, and ventilator dependence, displayed a facial grimace when staff moved the right arm during incontinence care, leading to an x-ray that suggested a possible hairline fracture of the right wrist, followed by a later hospital x-ray that showed no fracture. The facility’s investigation contained only three employee statements: from the RN and GNA providing care at the time of the observed grimace, and from a GNA who was not assigned to the resident but assisted with care that day. There was no documentation that staff from preceding shifts or days were interviewed, and no documentation that any residents were interviewed in response to the injury of unknown source.
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