Investigating on-site incidents and accidents
Editor’s Note: When an unfortunate event occurs involving a resident—a mysterious bruise, a fall, a wanderer found blocks or miles from the facility—the onus is on facility administration to determine the facts and respond accordingly. To do so to the satisfaction of the legal and regulatory systems, as well as the family and community, is no easy matter. Several years ago consultants Niki L. Rowe and Michael Amo of The Amo Group set out to determine facilities’ need for guidance along these lines and, in response, to develop a training manual meeting national standards. What follows is an excerpt from that recently published manual, Investigations in Long-Term Care Facilities: Implementing a Standardized Model, available from Vendome Group (see p. 50).
The process of becoming an investigator is more than memorizing and following the steps in a model. It requires that you learn to think like an investigator and inquire like an investigator. All this must be done using the scientific method. This chapter provides the basics for doing just that. Read it with an open mind. Practice it until its content is internalized.
It is one thing to follow the steps of an investigation like a recipe. Thinking like an investigator is another. Our goal is to teach you to think like an investigator. It will undoubtedly take more than a reading of this to accomplish that. It will take practice and skill development. So let’s begin.
Think Like an Investigator
A large part of being a good investigator is keeping an open mind throughout an investigation and following wherever the evidence takes you. To do this you must learn the thought processes and logic needed to undertake an investigation. Work hard at learning how to look at investigations and maximize the collection of all evidence. This entails knowing how to examine physical evidence, how to read documents and how to extract from witnesses all that they know. The reward is well worth the work.
Besides producing good investigations, learning how to think like an investigator has other benefits. When you have thought your way through an investigation, not merely followed prescribed steps, the following capabilities are greatly enhanced:
The ability to arrive at the right conclusion
The ability to explain every step of an investigation
The ability to defend your conclusion
Inquire Like an Investigator
You need only spend a little time with a seasoned investigator to notice his inquisitiveness. The desire to find answers is infectious. Their approach is to constantly search for fact-based answers to the follow-ing cardinal questions:
What actually occurred? (event)
Where did the event occur? (scene)
When did it occur? (time)
How did the event (likely) occur? (method)
Why did the event occur? (reason)
Who (or what system) caused the event to occur?
Although these are the basic questions of every investigation, there are many derivatives of these questions that surface during the course of an investigation. Facts that answer these six questions must always be sought regardless of the seriousness of the event being investigated. Answers to these questions are not pursued casually; they are part of an investigation plan based on the scientific method.
The Scientific Method and Investigations
The Amo Group’s “TAG Four Phase Model of Investigation” provides a series of systematic steps that overlay existing clinical review processes (also called the clinical track), thereby minimizing duplication of staff effort. It is based on the scientific method and adheres to fundamental tenets of police science.
Steps in the Scientific Method
Identify the problem.
Draw a conclusion.
To demystify the scientific method, know that it is already used in everyday life and in many activities within long-term care facilities. When trying to determine why your printer will not print (problem), you look for a reason (hypothesis). You check to see if the connections are tight (data). When you find a loose plug, you plug it in and the printer begins to print (test hypothesis). You conclude that the printer must be plugged in to work! In a long-term care facility, when a physician attempts to diagnose an illness, symptoms are considered (problem, hypothesis) and tests are run (collect data, test hypothesis). Based on the findings from these efforts, a diagnosis usually emerges (conclusion).
Again, the relevant steps are:
1. Identify the problem. According to the scientific method, the very first step in an investigation is to identify the problem. It is essential that an investigator clearly understand the allegation being made and the policy or regulation that allegedly has been violated. Clearly identifying the complaint to be investigated establishes the need to do an internal investigation by:
Clarifying which facility policies and procedures are in question
Identifying which state or federal regulations may have been violated
Confirming that an investigation is within the investigator’s jurisdiction, i.e., determining whether a law has been violated
A sample problem statement might be, “RN Peters observed unexplained or undocumented bruises on resident Mary Hughes’ left forearm.” Since there is not an explanation for the bruise, it is verified as an injury of unknown origin or source. This classification requires that a facility conduct an internal investigation. Failure to complete this critical step may result in a scattered inquiry. Furthermore, beginning with an unclear statement of the problem or event to be investigated compounds the difficulty of drawing a conclusion. Remember the final step of an investigation is to substantiate or disprove the allegation generated by an event.
2. Hypothesize. A hypothesis is an investigator’s conjecture about the answer to one or more of the six cardinal questions. There are usually two kinds of hypotheses used in internal investigations: working hypotheses and final hypotheses. When an investigator arrives on the scene of an event (problem) that has been verified to require investigation (administrative track), examination of the six cardinal questions is his starting point. Answers to these questions begin to paint a picture of what might have happened; they help the investigator understand the prob-lem (purpose of the investigation).
Based on answers to these preliminary cardinal questions about an event, an investigator usually can conjecture what might have occurred. However, the investigator must be careful not to allow this conjecture to bias the investigation. It is only an opinion and at best it initiates the development of an investigation plan. Yet as quality evidence begins to emerge, an investigator may create hypotheses regarding what could have occurred, who may have caused it, how it occurred, where it occurred, etc. These are called working hypotheses. These hypotheses are recognized as the starting point of an investigation. They may be viewed as targets toward which the investigator aims. If evidence fails to directly prove or disprove the working hypothesis, it is rejected and a new one is formulated. This formulation and testing of hypotheses until a story about what actually occurred emerges is the core of the scientific and investigatory process.
As an investigation nears its end these working hypotheses begin to flesh out some final hypotheses. Integral to creating final hypotheses are factually based answers to as many cardinal questions as possible and the application of these answers to re-create the event under investigation. The constant focus on times and dates (when) pays off here. By assembling answers to the cardinal questions chronologically, an investigator increases her confidence in the direction of the investigation. Depending on how thoroughly the process has been undertaken thus far, multiple final hypotheses should emerge. Once tested, these final hypotheses form the basis of the conclusion.
An example of a working hypothe-sis might be: A blood draw this morning caused the bruise on Resident Mary Hughes’s arm. If all the evidence supports this working hypothesis, the investigator can convert it to a final hypothesis, moving the investigation expeditiously to a conclusion.
3. Collect the data (evidence). Evidence is to an investigation as data is to a scientific inquiry. One of an internal investigator’s most important roles is to appropriately collect, preserve and analyze evidence. Because most internal investigators do the job on a part-time and as-needed basis, the process of managing collected evidence can be difficult and requires training and skill development. Typically investigators collect and review large amounts of evidence. Analyzing this evidence to test a hypothesis can be daunting, especially given the time constraints imposed by state and federal regulations. The process may be simplified by applying some basic tools and techniques.
Simplifying the Process
Test the Quality of Evidence
As discussed earlier in this chapter, an investigator’s first concern should be the quality of the evidence. To “think like an investigator,” you must establish the quality of the evidence by comparing it to each of the following five characteristics.
If evidence clearly fails to meet any one of the five characteristics, it must be rejected. When it is not clear whether the evidence meets or does not meet the five characteristics, it should be used with caution. In either case, it should be documented on the corresponding evidence record.
Once the quality of the evidence has been established, an investigator can begin to analyze it to cull the facts, assured that she is working with solid evidence.
Distill the Facts from the Evidence
As important as ensuring the high quality of evidence is making sense of it. A seasoned investigator will admit that collecting evidence and understanding its potential meaning are different tasks. Over time, an experienced investigator develops a number of useful techniques for finding the facts inside all the evidence collected. Yet there are “tried and true” approaches that will make this process easier and more efficient for the new investigator.
Summarize the evidence collected. It is useful to summarize in a sentence or two any important points or facts observed when a piece of evidence is collected and impressions are fresh. The evidence rec-ord for each type of evidence is the best place to record this information. However, some investigators may want to use an investigator’s notebook, as well. For example, “There was no evidence of a bruise listed in the most recent progress notes.” This will help remind the investigator to follow up on that point during interviews or other document reviews.
Categorize evidence. Group facts by their importance to a particular part of the investigation. Parts of interviews, documents and physical evidence may come to be associated with a particular theme or hypothesis of the investigation as it proceeds. Documenting on a separate page of the investigator’s notebook each theme/working hypothesis, with a list of supporting and conflicting evidence under it, helps prepare to test the hypothesis. The same approach is used to test the final hypothesis, which leads to the conclusion.
Subdivide evidence. Sometimes a large piece of evidence contains an overwhelming number of facts. In this case the evidence can be broken down into subparts to maximize understanding. An example might be a clinical history. Often large amounts of information about a resident’s past, development, family, medical condition, behavior patterns, etc., blur when read in a comprehensive narrative. However, when elements essential to the investigation are culled from the history and examined, an investigator is likely to get a clearer picture of the resident with respect to the event being investigated. One technique to accomplish this is to copy the document in question and highlight the portions of material interest. In the margin a note may be made on where this fact may fit in the investigation.
Look for corroborating facts. Sometimes a piece of evidence by itself is not credible, reliable or sufficient to stand alone. But together with other evidence it adds enormous weight to an investigation. For example, a CNA’s vague estimate of the time an event occurred may be refined by an activity roster and a progress note documenting a specific program in which the resident was participating. When these three pieces of evidence are examined together, the powerful fact of when the event occurred is established.
Use one piece of evidence to help collect others. One answer leads to another question. In interviewing, we refer to this as “drilling-down.” For demonstrative evidence, the position of furnishings, e.g., a lamp or a closet, may lead to questioning whether an eyewitness really could have seen what he said he saw.
Look for dates and times that will help reconstruct and produce a timeline for the event. Most investigators confirm that understanding the chronology of evidence in an investigation is essential to re-creating the event.
Understand which evidence is circumstantial and which is direct.
Look for gaps in evidence. The significance of these gaps may determine an investigator’s ability to substantiate the allegation under investigation. An investigator should be critical of the investigation process and the outcome. Trying to identify gaps or spaces in the timeline that cannot be supported by fact is an important exercise. If gaps appear, the investigator must review the evidence for an explanation or redo that part of the investigation that missed the evidence. If the gaps cannot be closed, an investigator must decide their significance in explaining the “who, what, where, when, how and why” of the event.
Review the investigation plan. The investigation plan should include all the steps needed to complete the investigation. Reviewing this plan from time to time provides an investigator with feedback about possible missed steps and steps yet to come.
As investigators practice the craft of internal investigation, skills improve in these and other areas. Applying these skills when analyzing evidence brings to light information that would otherwise remain hidden.
A fundamental tenet of the investigation process is: avoid assumptions. Let the evidence lead to the conclusion. An investigator must trust in and systematically follow the scientific process to ensure an effective investigation. Even so, there are traps to avoid. Here are a few obvious ones:
Do not let personal bias interfere with an investigation. Most investigations in long-term care are conducted by in-house staff with prior knowledge of personnel, operations and environment. While insightful, this knowledge can easily mislead an investigation. Be careful!
Do not let familiarity with staff affect the investigation. Similarly, relationships with or assumptions about coworkers can affect the objectivity of an investigation, e.g., “Sarah is a good person and would never abuse a resident.” Such thinking may lead to a less-than-thorough inquiry.
Do not rush to a conclusion. Sometimes external pressures push an investigation to a conclusion before every step has been taken. Under such pressure, gaps in an investigation are easily overlooked. This potential rush to a conclusion must be avoided.
4. Test the hypothesis. A principle strategy for all investigations is to constantly create and test hypotheses. When the evidence has been collected and analyzed, hypotheses (working or final) must be tested. Working hypotheses are the hypotheses an investigator uses from the beginning of an investigation to establish facts or what is known. We recommend that one hypothesis, minimally, be created for each of the six cardinal questions (i.e., who, what, where, when, how and why), although there is no limit to the number of working hypotheses an investigator may use. When an investigation approaches its end and enough evidence has been amassed, and each of the working hypotheses has been tested, an investigator can begin to create the final hypotheses that, once tested, can be the basis for formulating a conclusion.
Let’s see how this strategy works in a hypothetical situation. As an investigator arrives at the scene of a new investigation, he should be thinking about finding answers to the who, what, where, when, how and why of the event. As he learns more about the event, he can begin to formulate hypotheses for each of these cardinal questions. His task is to systematically collect evidence that will help him test these hypotheses.
Asking and answering questions, assembling facts, and establishing and testing hypotheses is the essence of an investigation. It is as basic as putting the puzzle together one piece at a time. Many pieces may be tried, but not all fit. Those that do fit are put in place and an image begins to emerge from the puzzle. If the puzzle is a snapshot of the scene of the event at the exact time it occurred, we are able to see what actually happened with each piece and each emerging image. To extend the metaphor, if our first image is of a person, we might now make a working hypothesis about who that person is. Put a few more pieces (of evidence) in place and we might be able to confirm our hypothesis. Then we will have the answer to the cardinal question who. By following the same process for each of the remaining cardinal questions, we can conclude the investigation.
When nearly all the pieces are in place, a more complete picture of the puzzle (or event) emerges. Now the investigator can create multiple final hypotheses explaining the various possibilities for how the event may have happened. By assembling all the evidence, he should be able to determine whether it proves one of his final hypotheses. If it does, he is ready to formulate a conclusion for the investigation.
To illustrate, let’s attempt to prove working hypotheses for two of the cardinal questions, where and when. Let’s say an investigator reviews a number of operational documents and talks with several employees during the early stages of an investigation (preliminary information). Let’s say (hypothesize) from these details it seems possible that the event being investigated occurred in the television room (where) during the 2:00 to 3:00 p.m. program (when). The investigator now has two working hypotheses:
The event occurred in the television room.
The event occurred between 2:00 p.m. and 3:00 p.m.
From the evidence assembled an investigator looks for facts that might prove these hypotheses. Interviews may identify an eyewitness to the event (direct evidence). Testimony may show that a loud noise, like two wheelchairs colliding, was heard coming from the television room around 2:30 p.m. (circumstantial evidence). A CNA’s testimony documents that a younger resident in his wheelchair was seen moving rapidly down the hall toward the television room around 2:30 p.m. (circumstantial evidence). Absent any contradictory evidence, these facts (though limited in number for this example) serve to prove the investigator’s two hypotheses relating to when and where the event occurred.
A good organizational tool for testing hypotheses is to list one at the top of a page in the investigator’s notebook. Then, beneath it, list the evidence that supports or refutes it. Such visualization helps the investigator accept or reject a working hypothesis. Even with apparent proof, an investigator should continue to look for additional evidence, listing it on the appropriate page of the investigator’s notebook. When an investigator becomes convinced that she has sufficient evidence to support or reject a hypothesis, that decision should be documented on the notebook page as the last entry.
5. The conclusion. This part of the investigation (or of the scientific method) is the easiest if the preceding parts have been done correctly and thoroughly.
The investigator is ready to draw the conclusion when, after thoroughly reviewing all the steps in her investigation, she is confident that:
She can describe in detail the event being investigated, as well as why it was investigated (verification).
She can describe every step taken, following the scientific method that led to her conclusion. This includes scene management, evidence collection and analysis, re-creation of the event, answering the cardinal questions and testing all viable final hypotheses.
She can articulate the reason she concluded that the allegation was substantiated or not substantiated, based on specific evidence.
Copies of Investigations in Long-Term Care Facilities: Implementing a Standardized Model, priced at $149 per copy, plus shipping and handling, are available by contacting Joyce Lembo at (212) 812-8971. Discount pricing is available for multiple-copy orders.
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