Deficiency Summary
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The facility received a deficiency for W154 §483.420(d)(3), Staff Treatment of Clients.
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The facility must have evidence that all alleged violations are thoroughly investigated.
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This requirement was not met as evidenced by: Based on interviews and record reviews, the facility failed to ensure that the documentation of facility investigation reports reflected that all serious injuries of unknown origin were thoroughly investigated for 9 of 11 reported serious injuries of unknown origin involving seven individuals (Individuals # 14, 38, 44, 45, 49, 56, and 69).
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The facility failed to ensure that the documentation of incident reports reflected that all non-serious injuries of unknown origin were thoroughly investigated for 88 of 105 reported injuries of unknown origin involving 66 individuals.
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