When a resident at facility A sustained a bruise of unknown origin on his right forearm, the director of nursing services (DNS) completed what she felt was a thorough investigation of the injury. However, during a subsequent facility visit, surveyors did not find evidence the DNS adequately investigated the incident and cited the facility for inadequate investigation.
Does this scenario sound familiar? Inadequately investigating an incident can trigger repercussions, including citations for noncompliance, inadvertently supporting plaintiffs’ legal claims, and, above all, negative effects on the resident’s well-being.
Thoroughly investigating all allegations and incidents is vital to gain facts, prevent recurrence, and maintain resident safety. Facility leaders should implement these tips to ensure their investigations are detailed and thorough.
Organization is Key
Merriam-Webster defines investigation as a “study by close examination and systematic inquiry.” To inquire systematically and examine all factors thoroughly, organization is key. Facility leaders must plan and prioritize, recognizing that some parts of an investigation will require more time than others.
Often, facility leaders conduct multiple investigations simultaneously, because they know that all allegations and incidents should be reviewed or investigated, not just those confirmed or involving a crime.
An organized approach enables the thorough review necessary for regulatory requirements, even when conducting multiple investigations. The 4-step process below can help facility leadership remain organized so they can conduct thorough investigations.
Step 1: Determine the purpose for the investigation.
The first step of the process is determining the purpose(s) of the investigation and answering, “Why is an investigation being conducted?” Articulating purpose helps guide the investigator to avenues the investigative process should explore.
For example, a bruise of unknown origin investigation may include the following purposes:
- To determine why the bruise occurred
- To determine if abuse occurred
- If abuse occurred, to identify the perpetrator for disciplinary action
- To identify other residents who may be similarly affected
- To learn why a bruise of unknown origin was not promptly reported per facility policy.
Step 2: Develop a plan for the investigation.
First and foremost, facility leadership must ensure the residents involved or affected are safe. Next, facility leaders should develop an investigation plan by asking:
- Were all required entities notified, such as the department of health, local authorities, boards, etc.?
- Who will lead this investigation?
- Will anyone else be needed to assist?
- What evidence should be reviewed?
- Who should be interviewed?
- Who will conduct the interviews?
- Are staff involved, and does that involvement require temporary suspension pending the investigation’s findings?
Step 3: Review tangible evidence and conduct interviews.
Relevant tangible evidence may include in-house documents, like medical records, billing statements, staffing records, personnel files, schedules, or policies and procedures.
Other documents might come from outside sources, such as hospital or emergency medical service records or police reports. Evidence like camera footage, incident reports, or digital call- light printouts may also be needed to help the investigator determine what happened and the root cause(s).
Tangible evidence to review for a bruise of unknown origin may include:
- Resident A’s medical record, including diagnosis, recent diagnostics, nurses’ notes,
- and medication and treatment sheets
- Assessment and observations of
- Resident A
- Incident report
- Visitor log
- Staffing assignments and staff schedule
- Equipment used to aid the resident to ensure it is in working order and does not need repairs
- Assessments and medical records of residents in similar situations, often referred to as “like residents,” to determine if other residents also have similar injuries.
Conduct Interviews
Although it may not always be possible, try having two interviewers in each interview, one to ask the questions and another to write the statement or note-take.
It is best practice to have at least one interviewer present for all interviews. This is important for two reasons. First is consistency, so that all interviewees are asked the questions the same way. Second is the need to assess witness credibility, especially if it is one person’s word against another. It may be necessary to interview some people multiple times, especially if there are contradictions.
Before the start of the interview process, the interviewer should have standard questions to ask the interviewees, such as “Have you worked on A wing in the last month?” or “Have you ever cared for Resident A?” After easing into those questions, the interviewer can probe the situation in more detail.
Any residents involved in the incident should be interviewed unless they are semi-comatose or comatose. An investigator might erroneously not interview residents with impaired cognition, believing the impairment prevents the resident from giving any pertinent information.
Generally, this is mistaken. When interviewing residents, the interviewer is trying to determine if the resident perceives they have experienced harm, as well as details that help establish timelines and may identify root causes. Those with cognitive impairment can still contribute their perspective.
The interviewer may wish to consult with corporate staff or legal counsel before interviewing family members and visitors to receive any special instructions on how to conduct the interviews—such as who should conduct it or if the interview should occur with family members separately or as a group.
Each interview should yield a written statement. For people who are interviewed multiple times, prepare a separate statement for each interview and clearly mark each with the date and time. If there are contradictions in the statements, documenting this way will help to show discrepancies.
Interview More People
A common mistake investigators make is not interviewing enough people. Leadership must ensure the interview process is exhaustive and includes all who may be involved, including those who may have witnessed or been affected by the incident. For example, in the bruise of unknown origin scenario, leadership may wish to interview:
- Resident A
- Resident A’s roommate
- Like residents
- Staff and volunteers with access to Resident A who worked during the two-week period when the bruise is believed to have occurred
- Visitors who had access to Resident A in the same time period.
Step 4: Conclude and follow up.
After reviewing the evidence collected and conducting interviews, the investigator conducts a root-cause analysis. Once the investigator makes a reasonable determination of cause, the facility must follow up to close the investigation.
Follow-up may include completing mandatory reports, such as the facility-reported incident (FRI) sent to the department of health, education needs, disciplinary actions, or policy and process changes.
The nursing home administrator or designee may wish to again consult corporate staff or legal counsel before conversations with family members, especially if the information being relayed is negative. Facility leaders should also inform the medical director of the investigation’s outcome. Then, update the medical record and provide any reimbursement, as necessary, in cases of theft or misappropriation.
Conducting a thorough investigation ensures no details are missed and that the voices of all involved in the allegation or incident are heard. It also mitigates risk of survey issues, litigation, and recurring safety issues. Facility leaders should prioritize thorough investigations and reassess processes now to avoid the possible repercussions of inaction or inadequacy.
Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at dwinzeler@aapacn.org.
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