F0610

D

Failure to Thoroughly Investigate Missing Property and Injury of Unknown Source

Minocqua, Wisconsin Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct timely and thorough investigations into allegations of abuse and misappropriation of resident property for two residents. For one resident, the facility was notified that personal property, including $80 in cash, was missing. Although the grievance was reportedly filed by the family member, the facility did not begin its investigation until two days after being made aware of the missing items. The only documented investigative action was a grievance/complaint form indicating that staff searched the resident’s room and laundry, waited a couple of days, rechecked laundry, and then contacted the resident’s daughter about replacing the items. No documentation was provided to show that staff or other residents were interviewed, and the facility was unable to locate the missing property. The surveyor requested the facility’s internal investigation multiple times over several days and was only provided the single grievance form, with no additional investigative documentation.

For the second resident, the deficiency centers on the facility’s incomplete investigation into a pelvic fracture of unknown origin. This resident had a history of falls and multiple fall-related care plan interventions, and had moderate cognitive impairment as evidenced by a BIMS score of 9/15. On the morning in question, the resident began to complain of pain but initially denied falling. A progress note, lacking date, time, and author, documented that the resident complained of left hip pain, denied any falls during the night, was given acetaminophen, and that an x-ray was ordered. Due to weather-related delays with mobile x-ray, the resident was sent to the ER, where imaging revealed a markedly comminuted fracture of the left acetabulum and a nondisplaced fracture of the left inferior pubic ramus, with associated hemorrhage.

The facility’s investigation into the resident’s injury did not meet its own policy requirements for a thorough abuse or injury-of-unknown-source investigation. The investigation worksheet identified two staff members, an LPN and a CNA, as involved or potential witnesses, and only these two staff were interviewed. The LPN reported finding the resident partially off the bed and assisting the resident back to bed without signs of pain, and the CNA reported responding to the resident’s calls during the night, noting restlessness but no complaints and that the resident was asleep when the Foley catheter was emptied. The worksheet documented that no interview was conducted with the resident by facility staff, that a complete physical and emotional assessment identifying areas of injury was not completed, and that there were no new interventions or clear conclusions about how or why the incident occurred. It also noted that documentation in the resident record was not complete and left sections regarding root cause, care plan revisions, and other corrective actions unanswered. The nursing home administrator confirmed that the paperwork submitted to the state constituted the entirety of the 5-day investigation and that no additional investigation was performed.

Across both examples, the facility’s actions did not align with its written policies on abuse prevention and abuse investigation and reporting, which require prompt reporting, thorough investigation, and interviews with the resident, the reporter, witnesses, and staff on all shifts who had contact with the resident during the relevant period. In the case of the missing property, the facility did not document interviews or a comprehensive inquiry into the alleged misappropriation. In the case of the pelvic fracture, the facility did not complete a full assessment, did not interview the resident, did not identify a root cause, and did not fully document the incident in the medical record, resulting in an incomplete investigation of a serious injury of unknown source and failure to rule out abuse as required by policy.