Deficiency Summary (cont'd)


A summary of specific relevant evidence noted by the surveyor includes:

  • The 88 injuries of unknown origin involving 66 individuals (nine of whom had serious injuries) were not thoroughly investigated. Surveyors provided specific evidence to support each instance.
  • The facility investigator stated that facility investigation reports do not mention staff interviewed who had no input as to injury cause. The investigator further stated he felt that IDT investigation findings were adequate.
  • The quality assurance (QA) specialist confirmed that investigations of unknown-non serious injuries do not include interviews with staff to attempt to determine cause and/or rule out/confirm abuse/neglect. Further, the QA specialist stated that the assistant unit director (AUD) is responsible for unknown, non-serious injury investigations.
  • The AUD stated that observation notes are reviewed for these types of injuries and that interviews with staff are rarely part of the process.
  • The assistant superintendent for programs revealed that investigation findings typically only restate information contained in the incident report