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January 2006

The Importance of Performing Thorough Investigations

In a recent letter to surveyors, the Centers for Medicare and Medicaid Services (CMS) announced they are working with various agencies, including a Johns Hopkins University forensic investigator, to design a national curriculum tailored to improve the investigative skills of state surveyors.

So how concerned should nursing home administrators be by this action? They can expect more rigid oversight, allegations and deficiency tags directed toward their facility – unless they, too, enhance their own investigative programs and staff skills. Consider the results of this recent state survey regarding a facility’s investigation of a resident’s minor injury. A nursing facility was cited for failing to conduct a thorough investigation following the discovery of a skin tear of unknown origin on a resident’s hand. In the citation, the state surveyors alleged the facility failed to indicate a comprehensive, systematic investigation based on the following:

• There was no specific mention of where the injury occurred on the
  resident’s hand.

• The investigator attributed the injury to the resident’s condition, citing poor standing balance and poor safety judgment. However, there was no indication how either of these factors might have played into the injury.

• The investigator concluded that the source of the injury was from the resident’s hand dangling over the arm of her wheelchair and making contact with the wheelchair. This inference was not based on the data presented, and there was no documentation of any inspection of the wheelchair for rough surfaces.

• Only the nursing assistant who first identified the skin tear was interviewed. There were no interviews with other staff that might have observed the resident at other times with her hand dangling in a manner that could cause injury.

Could this same situation happen at your facility? Probably so, since very few administrators and nurses have received any formal training on investigating incidents. Without proof the facility conducted a thorough investigation of incidents involving resident injuries or possible abuse or neglect situations, administrators set their facilities up for allegations by not only surveyors, but family members, attorneys and possibly the media.

The best way to safeguard your facility against allegations and ensure residents are safe and able to reach their highest practicable function is to follow the actions taken by CMS and acquire the training and resources needed to develop an investigative program your staff can skillfully and competently use.

Linda Williams, RN, BSN
Long Term Care Risk Manager, Guide One Insurance

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