Jeannine LeCompte, Publishing and Research Coordinator
Internal investigation issues are those incidents or events at long-term care facilities (LTCs) which are brought to the compliance officer’s attention through a means other than a “hotline” or similar reporting method. These other means can include a conclusion drawn from an internal review process, or a notification from a third party.
Staff should all be educated to know that they are legally required to report suspected abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, any potential crime, and any other issues which might affect the LTC’s standards of service delivery.
If staff bring information to the attention of the administrator or compliance officer, it is important that the initial reporter is kept informed of the investigation and whether it resulted in a report to the Department of Health (DOH) and/or law enforcement.
If the event does not meet the abuse definitions, the analysis leading to that conclusion must be clearly documented. The facility’s Incident Review Policy should then be followed. This should result in the evaluation of the event to determine cause, future preventative actions, and reporting to the Quality Assurance and Performance Improvement (QAPI) program.
If there is reason to believe that the reported incident might have criminal or civil liability, then the facility administrator, the DOH (through the Electronic Incident Reporting System), and local law enforcement must immediately be notified. An episode of abuse with injury has a two hour reporting window. Following that, a full and complete abuse investigation should take place.
Interviews should be conducted in a private location, preferably seated, in order to maintain eye conduct with the individual being interviewed. Impartiality, discretion, and confidentiality are all very important. Open-ended, non-leading questions are best, as well as non-judgmental language. If necessary, conduct follow-up interviews to evaluate any new information obtained, changes in information, or discrepancies.
Document investigations thoroughly, and include:
- The date and time the incident was discovered or identified
- The person who discovered it
- How the incident was discovered
- Description of the resident including information about any conditions prior to, and upon discovery, of the incident
- Where the incident occurred
Keep all collected information including documents pertaining to interviews and evidence organized in a secure file. This is important not only for recordkeeping, but it will also help provide legal protection should an outside regulatory authority eventually be called in. The facility can be held legally liable for poor recordkeeping of any incident or event which affects service delivery.
