Failure to Thoroughly Investigate Injury of Unknown Origin and Alleged Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for one resident with severe cognitive impairment and dementia. The resident was re-admitted with dementia and had a BIMS score of 0/15, indicating severely impaired cognition. A nursing note documented that a CNA informed an LPN during report that the resident had a hematoma on the left elbow, and the resident was noted to be on an anticoagulant. A facility report indicated the resident was reported to have a bruise on the left elbow and was unable to say what occurred. A 5‑day summary stated that a thorough investigation was conducted and concluded that a shower the prior day was the most probable cause of the bruise. However, review of the investigation showed there was no evidence of resident interviews and no evidence that the LPN who was notified of the bruise was interviewed. The LPN later stated he had observed the resident pulling on his Geri‑sleeves and had spoken with the DON the next morning, and the DON confirmed that the LPN was not interviewed during the investigation and stated that no resident interviews would be conducted because it was an injury of unknown origin. The deficiency also involves the facility’s failure to thoroughly investigate an allegation of physical abuse for another resident who was cognitively intact with a BIMS score of 14/15. A nurse’s note documented that the resident had a care concern with a CNA, and that the CNA was immediately removed from assignment. A 5‑day follow‑up report described that the resident reported to the supervisor that while she was looking for her cell phone, the assigned CNA insisted on putting her to bed first, then looking for the phone, and that the CNA grabbed her arm and removed her dress with force, causing the resident to scream that her arm was being hurt. The facility’s summary and conclusion substantiated staff‑to‑resident abuse. However, review of the investigation revealed that not all staff working at the time were interviewed, and there was no documentation of interviews with the roommate or other residents. The DON stated that roommate and other resident interviews were not documented and that additional staff were not interviewed because the roommate’s confirmation of the abuse was considered sufficient, despite the facility’s policy requiring that all incidents be investigated promptly and thoroughly, including interviewing residents, witnesses, and involved staff, with all interviews and findings documented in a confidential investigation report.
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