Failure to Timely and Thoroughly Investigate Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into an alleged resident-to-resident abuse incident and an injury of unknown origin. One resident reported that another confused resident entered the room, was told to leave, then grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. This event was documented in a nursing progress note as occurring during the evening shift, with staff intervening, separating the residents, and notifying leadership. However, when surveyors requested the investigation related to this resident-to-resident altercation, the current Nursing Home Administrator was unable to locate any investigation, and the DON stated that the former administrator would have handled it. No Facility Reported Incident investigation or related investigative documentation was provided for this event, despite facility policy requiring assignment of an investigation, interviews with staff on all shifts who had contact with the resident, and review of events leading up to the alleged incident. The facility also failed to promptly and thoroughly investigate an injury of unknown origin involving the same confused resident who was later found to have a skin tear/abrasion to the head during a skin check. The injury was identified and documented in the resident’s record, but the investigation was not initiated until three days later. The written investigation for the head abrasion stated that fall protocol was reviewed, staff statements were collected, a skin assessment was completed, and appropriate parties were notified, but the factual discoveries section was left blank. Surveyors noted that the CNA and LPN who first identified and documented the injury on the shower sheet and in the progress note were not interviewed, and the DON could not explain the source of the injury. The NHA stated that such a head injury would be considered an injury of unknown origin and that the expectation was for immediate initiation of an investigation, including review of history, resident and staff interviews, and review of interventions, which did not occur as required by facility policy.
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