Failure to Conduct and Document Resident Interviews and Assessments in Abuse Investigations
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate two separate allegations of abuse related to injuries of unknown origin for two residents. For the first incident involving Resident #74, the initial incident report listed actions such as initiating an investigation and notifying the family, physician, medical director, and ombudsman, but did not include resident interviews or resident assessments as immediate protective steps. Review of the facility’s abuse investigation file showed eight staff interviews but no resident interviews or assessments. The follow-up investigation report also confirmed that only staff were interviewed. During interviews, the Nursing Home Administrator (NHA) acknowledged that including both staff and resident interviews is best practice and stated she believed the social worker had completed resident interviews. The DON reported that they do not interview residents who are considered non-interviewable, instead looking for signs or symptoms of abuse and contacting families, and indicated that any screening would be documented through skin assessments. However, the DON could only produce a limited number of skin assessments for some non-interviewable residents and these were not clearly tied to the abuse investigation. For the second incident involving Resident #140, the initial incident report for an injury of unknown origin documented steps such as initiating an investigation, completing a head-to-toe assessment, medicating for pain, notifying the physician, responsible party, and medical director, ordering an x-ray, and updating the care plan, but again did not list resident interviews or broader resident assessments as part of the immediate protective actions. The abuse investigation file contained nine staff interviews but no documentation of resident interviews or assessments. The follow-up investigation report indicated that only staff and the involved resident were interviewed. The NHA confirmed the investigation file was complete, reiterated that she believed the social worker had conducted resident interviews, and produced an email stating that three residents on the same hallway had been interviewed, but no written interview documentation could be provided. The DON stated they do not interview non-interviewable residents, instead monitoring for signs or symptoms and contacting families, and was unable to provide any documentation of completed resident assessments related to this incident, demonstrating that resident interviews and assessments were not consistently conducted or documented as part of the abuse investigations.
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