Failure to Investigate Injury of Unknown Origin and Alleged Misappropriation of Property
Penalty
Summary
The facility failed to follow its abuse, neglect, and injury-of-unknown-origin policies when a resident developed significant bruising to the left arm and when an allegation of stolen prescription glasses was made. The facility’s policies required immediate notification of the Nursing Home Administrator and DON, coordination of a thorough investigation with witness statements, interviews of all potentially involved or observing parties, assessment and documentation of injuries, and timely reporting to the state agency and law enforcement when indicated. The resident’s responsible party emailed the social worker with photos of serious bruising on the resident’s left arm and questioned its cause. Although an RN assessed the arm and noted a large bruise to the upper forearm, there was no clinical record documentation of the bruise, including size or color, and the weekly skin check for that date recorded no skin issues. Staff statements indicated the resident reported he had scratched himself and denied anyone grabbing him, and the Administrator and DON acknowledged that no thorough investigation was completed due to accepting this explanation. The facility also failed to investigate and report an allegation of potential misappropriation of the same resident’s prescription glasses. The resident’s responsible party filed a grievance stating that the resident’s prescription glasses had been stolen previously and that another pair left at the bedside was now missing, using the word “stolen,” and noting that the eyeglass case remained in the room but not the glasses. The social worker documented the grievance and the use of the term “stolen,” but there was no investigation documented in the clinical record into the potential misappropriation of property. The Administrator and DON confirmed that the facility did not complete an investigation, obtain witness statements, or notify law enforcement or the Department of Health regarding this allegation. These failures occurred despite facility policies requiring timely and thorough investigations and reporting of alleged neglect, injuries of unknown origin, and misappropriation of resident property.
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