Deficiency Summary - Example Part 1

The deficiency states:

W154 – §483.420(d)(3), Staff Treatment of Clients

The facility must have evidence that all alleged violations are thoroughly investigated.

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 #'s 14, 38, 44, 45, 49, 56, and 69) and 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.