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The Importance of a Thorough Investigation: What You Need to Know

As a director of nursing services or an administrator of a long-term care facility, you naturally hope that the day-to-day care, services, and activities that happen within the facility proceed without incident. However, despite precautions and oversight, reportable incidents do indeed occur. That’s why it is imperative that, when they do, you have policies and procedures in place to conduct a thorough investigation and that you implement processes to prevent similar incidents from occurring again.

Otherwise, not only are you potentially putting your residents in grave danger, you are putting the facility itself at risk. If a reportable incident is not thoroughly investigated and properly reported, the facility could well be cited for deficiencies—some as severe as “immediate jeopardy.” You could be fined with a civil money penalty, you could have your admissions suspended by the state or the Centers for Medicare & Medicaid Services, or you could place your facility at risk for potential lawsuits.

As part of the AADNS annual conference, Madeline Coleman, JD, MS, RN, CPHQ will host a session to educate long-term care leaders on this very issue—and how you can take steps to implement thorough investigations within your own facility. The session, titled “Conducting a Thorough Investigation on Reportable Incidents in Nursing Homes,” will be held on Thursday, June 28, 2018, at 3:30 p.m.

Coleman, who worked for a state agency regulating nursing homes for 15 years before retiring in 2016, says that federal regulation requires that several common incidents be reported to the state agency. Those are abuse (including physical, sexual, verbal, and mental abuse), neglect, injury of unknown origin, and misappropriation of property. Each state has its own list of reportable incidents, as well.

Using the incident of abuse as an example, Coleman says these are some of the key steps to take in conducting a thorough investigation:


  1. Ensure that the victim and other residents are protected from the abuser

In one case that Coleman will go over in her session, a nurse walked in on inappropriate sexual behavior occurring between a resident and a visiting relative. The nurse left the room and did not take action immediately to stop the alleged abuse.

“She did not do anything about it right away. She went back to the nurse’s station. That alleged abuser was allowed to stay in that room some additional time, and when she went back for a second time, he still had his pants almost down and she still did not do anything. The first thing she should have done was not leave that patient alone with that alleged abuser,” says Coleman. “She should have used a call button to call someone for assistance.”

 2. Conduct thorough interviews with all potential witnesses

In a real-life example that Coleman saw when she was working for the state agency, a facility had a resident who reported being raped. When the facility leadership conducted an investigation of the incident, only people who had had direct contact with the resident were interviewed, such as the CNAs and nurses working directly with that resident.

“There was a male working in dietary that they did not interview. There were males that they had outdoors. They had a contractor coming in. It did not matter that the resident was in one hall and the work was being done in another hall. You cannot automatically assume because the worker was supposed to be somewhere that the worker did not do that, that the dietary person did not do that. So you need to be looking at every component for the investigation,” says Coleman.

3. Make sure all relevant data is in the investigative file

You should have an investigative file containing all the information that you have gathered during the investigation, says Coleman. That way, during surveys or other outside investigations, you can hand over all the information you have, as well as prove that you conducted a thorough investigation of the incident.

“When we surveyed facilities, a lot of times that information was piecemeal. So they had to go find information that was in one place, and then they had to go look for something somewhere else. Certain documents should automatically be with your investigative file so that whether it’s state agents coming in or some other agency like adult protective services, you can just say, ‘Here’s the file with all the information that you need,’” says Coleman.

4. Train the staff on proper policies and procedures

It’s not enough to simply have investigative policies and procedures in place, says Coleman. The staff must also be trained on them.

“If you’re aware of an incident, whom do you report it to? How long do you wait to report this incident? Most incidents have to be reported within 24 hours. There should be a policy that outlines for whoever is reporting the incident, what that person should do. Because sometimes we found that staff delayed in reporting incidents,” says Coleman.

For example, at midnight a CNA witnesses another CNA abuse a patient. She shouldn’t wait until the next morning when the director of nursing services comes in to report the incident, says Coleman.

“She needs to report that to a supervisor. Then a supervisor makes a decision whether to call the DON right away. But you should have it spelled out in a policy, so they know exactly what they need to do. Because sometimes when we’d interview staff about different incidents, they would tell us, ‘Well, we didn’t know what we were supposed to do.’ And that’s never a good answer,” she says.

Coleman goes into much more detail in her AADNS conference session. Modules of the session include:

  • The elements and components of an investigation
  • Collecting and preserving evidence
  • Tips for interviewing witnesses
  • Documents that your investigative files should contain

And much more. So if your facility’s investigation policies and procedures could use some updating, consider joining in on this session. It could prove vital to your facility and your residents.

“Whether facilities realize this or not, a thorough investigation is very important,” says Coleman. “One of the questions I’m asking you is, ‘Have you ever been cited by a state agency for not conducting a thorough investigation?’ If your answer is yes, then this seminar is for you. And even if your answer is no, this is still a seminar for you, because you don’t want to place your residents at risk that can result in high-level deficiencies by the state due to not conducting a thorough investigation.”



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