Incomplete Incident Investigations and Lack of Incident-Specific Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct comprehensive investigations and implement appropriate, incident-specific interventions following two separate facility-reported events. In the first event, a resident with moderate cognitive impairment (BIMS score of 11) exited the building in a wheelchair through an alarmed entrance door that had been opened by a non-employee vendor, which prevented the door alarm from triggering. Staff were unaware the resident had left the building and only became aware when a family member reported the resident was outside; video surveillance later showed the resident was outside unsupervised for an estimated 15 minutes. The facility’s investigation and documentation identified the resident’s impaired memory, confusion, and desire to smoke as risk factors and focused on staff response to door alarms, but did not accurately identify or address the root cause that the resident was assisted out by a vendor and that no alarm had sounded. In the second event, a resident was found in bed with urine-soaked clothing and a soiled brief by oncoming staff after shift change, following care responsibility by a night-shift CNA. The incident was reported up the chain of command, but the facility was unable to produce documentation showing that the resident’s responsible party or provider had been notified, nor could it provide risk management or event forms with detailed information about the incident. The facility’s written findings referenced interviews with other residents on the hallway, review of security camera footage, the CNA’s resignation, and an interdisciplinary team conclusion that there had been a lapse in care and that the incident was isolated. However, there was no complete and thorough documentation of the investigation, interdisciplinary team notes, event review, staff education, or evidence of required notifications, despite facility policy requiring comprehensive written procedures and documentation for investigations and reporting of alleged abuse, neglect, and exploitation.
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