Failure to Conduct Separate and Thorough Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving one resident. The resident was admitted with diagnoses including muscle weakness and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A progress note dated 11/27/25 documented that during incontinent care, while the resident was being turned in bed, both lower extremities slid off the bed and touched the floor while the upper body remained on the side of the bed. A statement from the RN involved indicated the resident was not injured and did not exhibit signs of pain after this fall. The unit manager LPN stated that the facility’s process requires the assigned nurse to report incidents to the nursing supervisor, who is then expected to obtain, on the day of the incident, signed and dated witness statements from all staff involved and to start the investigation. The resident’s care plan included a focus area for right hand swelling and bruising, initiated on 12/01/25. However, the DON reported that there was no separate investigation conducted for the 11/27/25 incident apart from an investigation related to a later incident on 12/03/25. The DON also confirmed that the swelling and bruise identified on the resident’s right hand on 12/01/25 did not have a separate investigation to determine how or when the injury occurred. As a result, the facility did not follow its stated process for timely and complete incident investigation and failed to investigate the origin of the resident’s right hand injury, leading to the cited deficiency under NJAC 8:39-4(f).
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