F0610

E

Incomplete and Untimely Abuse and Fall Incident Investigations

Seattle, Washington Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct thorough and timely investigations into alleged abuse and an unwitnessed fall, contrary to regulatory requirements and the facility’s own policies. The Nursing Home Guidelines (“Purple Book”) require that all alleged violations be thoroughly investigated, with results reported to the administrator and appropriate officials within five working days. The facility’s abuse policy also requires thorough investigations and interviews with other residents to whom the accused employee provides care or services. However, for multiple incidents involving three residents, investigations were either delayed beyond the five‑day requirement or lacked essential documentation such as interview dates, resident names, and staff interviews.

For one resident with intact cognition, an incident investigation dated 02/16/2026 was initiated after another resident reported witnessing this resident being abused by a staff member. The investigation included an undated interview form in which the resident denied inappropriate touching and six additional interview forms that lacked resident names and dates, listing only room numbers. The summary and conclusion of this investigation were not completed until 03/17/2026, which was beyond the five working days allowed. The Assistant DON confirmed they did not conclude or summarize the investigation until almost a month after the allegation, and the DON stated that interviews should be dated and include resident names, and that investigations were expected to be completed within five working days.

For another cognitively intact resident, an incident investigation dated 02/19/2026 documented that the resident complained a recreation staff member called them a derogatory name during a conversation, and that the staff member admitted to the communication issue, stating they were joking. The investigation concluded that the staff member did call the resident a derogatory name, and included five other interview forms that again lacked resident names and dates, listing only room numbers. The DON stated that all resident interviews should be dated and include resident names, noting that using only room numbers could make it difficult to identify who was interviewed if residents changed rooms or were discharged. In a separate unwitnessed fall incident for a resident with a stroke, cognitive impairment, and total dependence for transfers and mobility, the investigation documented that the roommate saw the resident get up from bed, move toward a chair, and stumble, with unclear documentation on where the resident landed or whether they hit their head. The investigation did not include any staff interviews. A RN, the LPN/Unit Manager who completed the investigation, and the DON all stated that staff interviews, particularly with the assigned nursing assistant and any staff who had contact with the resident prior to the fall, were expected and should have been included to complete the fall investigation.