Personnel investigations

Personnel investigations are necessary whenever there is an allegation or indication of employee misconduct. According to Federal Regulation F-225, “The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law through established policies.”

Clearly, it is every staff member’s responsibility to report any suspicion or indication of employee misconduct and in turn, it is administration’s responsibility to immediately follow up with an internal investigation. If either of these actions goes unheeded, the safety and security of both residents and the facility can be jeopardized. Please review the following situation and make changes as appropriate in your facility.

The situation

One evening, a newly hired CNA was asked to assist an elderly woman with her shower. The woman was frail and totally dependent upon staff to meet her needs, as she had a history of respiratory and heart disease, as well as severe dementia. She used a wheelchair for mobility and required the assistance of two staff members with all transfers. Additionally, she drank alcohol daily and often exhibited negative behaviors when staff attempted to care for her. Before starting the shower, the CNA searched for, but could not find, someone to help transfer the woman from her wheelchair to the shower chair. The woman was becoming agitated, so the CNA asked her to hang onto the grab bar in the shower room as she attempted to transfer her alone.

A background check came back indicating the CNA had previously been convicted of domestic violence, harassment, and theft.

As this was occurring, another CNA walked past the shower room door and heard a commotion inside. Upon entering the room, she found the woman on the floor with the new CNA beside her. The new CNA explained that the woman had begun to slip from her wheelchair, so she gently lowered her to the floor with the use of her gait belt so she would not get hurt. The second CNA asked the woman if she was all right, but the woman remained agitated and upset. There were no visible injuries, so the two CNAs assisted the woman with her shower and reported the incident to the charge nurse afterwards.

Upon hearing about the incident, the charge nurse checked the woman and later documented that she “saw no sign of injuries, however the resident complained of right knee pain, even though her knee was not bumped while being lowered to the floor.” The nurse gave the woman a mild pain reliever and reported the incident to the next shift nurse. During the night, the woman continued to complain of right knee pain and was given more of the pain reliever.

By the next morning, the woman was in excruciating pain and her right knee was considerably swollen. When the day shift nurse arrived, she quickly notified the woman’s physician and family of the situation. The physician ordered a stronger pain reliever and a portable x-ray of the injured site. When the x-ray results came back, it revealed that the woman had a fractured right femur, so she was sent to the hospital for treatment. Three days later, the woman returned to the nursing facility, but her condition had deteriorated to the extent that hospice services were requested and she died just days later.

Upon being notified of her death, the woman’s family complained to the state nursing home licensing bureau. In response, a survey was conducted that resulted in severe deficiency tags and a $10,000 fine for the facility. Some of the allegations included:

• Staff did not follow the woman’s care plans.

• Staff failed to notify the physician and family in a timely manner.

• Staff did not properly assess the resident or investigate the incident.

During the survey, the investigators interviewed key staff members. They discovered that a background check had been conducted before the new CNA was hired. However, the check came back indicating the CNA had previously been convicted of domestic violence, harassment, and theft, for which she subsequently completed anger management classes. Her personnel file reflected that she received a verbal reprimand for not following the woman’s plan of care, and nothing else.

All of the CNAs that worked the evening and night of the incident were additionally interviewed, including the aide who had helped to finish the woman’s shower. That CNA stated that during the shower, the woman seemed to cry out in pain a few times, but the new CNA always interrupted her by telling her “she was all right.” After the shower, the new CNA tried to talk her coworker out of reporting the incident to the charge nurse, but the coworker did it anyway. Other CNAs told the surveyors how that evening the new CNA joked about the incident and said she “would never care for that [derogatory name] again.”

The surveyors also interviewed the charge nurse on duty at the time of the incident and asked why she did not follow the facility’s “Resident Fall” protocol by notifying the woman’s family and physician of the incident and her complaint of pain. The nurse replied that she did not consider the incident to be a fall, since the CNA reported that she gently assisted the resident to the floor. Indeed, no one at the facility had questioned the CNA’s story, even though the facts indicated that an obvious trauma occurred.

Shortly after the survey concluded, the new CNA and the charge nurse were terminated for reasons directly related to the incident. Additionally, the woman’s family notified the administrator of their intent to sue the facility. Subsequently, a mediation was held and a settlement was agreed upon by all concerned parties.

Safeguarding your facility

Personnel investigations are necessary whenever there is an allegation or indication of employee misconduct, as was the case in this situation. Serious allegations such as assault, sexual misconduct, or abuse may require that the accused be suspended pending administrative investigation. Under these circumstances, administrative personnel should report the incident to the proper authorities and involve their human resources director and legal counsel to ensure that the investigation is conducted properly.

Upon first learning of an allegation of employee misconduct, a preliminary investigation should be conducted to determine the nature of the situation and whether staff is indeed involved. If a decision is made to proceed with a formal investigation, interviews should be conducted as soon as possible to preserve recollection and to capture important information. The following are some tips regarding the interview process:

1. The interview should be conducted by an objective, neutral party to eliminate bias.

2. Make a list of who should be interviewed, such as the staff involved in the resident’s care at the time of the incident and anyone else who can reasonably shed light on the situation.

3. Determine the order in which the interviews will take place. Protect employee privacy by spacing the interviews far apart from each other.

Paraphrasing or summarizing the words of another inserts a potential source of bias, and can be considered less reliable.

4. Prepare a standard list of topics to be covered, rather than trying to “wing it.” Include topics, such as the time frame of contact with or observation of the resident; involvement or interaction with the resident; and observations of others’ interactions (for example, staff, visitors, or family). The list of questions and topics will differ for the victim, complainant, family members, alleged perpetrator, and witnesses.

5. Allow sufficient time for the interview and provide privacy with decreased distractions. Don’t hurry the conversation or interrupt the person while he or she is talking.

6. Ask open-ended and nonleading questions. You want the interviewees to tell their story in their own words. Encourage them to re-create and describe their involvement, yet caution them to state only the facts (i.e., what they observed or heard) and to not speculate.

7. Avoid compound questions, such as, “What were you and the resident doing at the time…?”

8. Avoid emotional discussions and never become argumentative, angry, or interrogative. If an employee refuses to participate and wants to leave, he or she should not be stopped. However, you can inform the employee that leaving the interview will be considered as a failure to cooperate, which may result in disciplinary action up to and including termination. Alternatively, if an employee chooses to resign rather than to be interviewed, have the employee sign a statement reflecting that decision.

Use a standard format or form to document the interviews and subsequent investigation. Some states require that witness statements be written by the witness and no one else. Paraphrasing or summarizing the words of another inserts a potential source of bias, and can be considered less reliable because the reviewer will need to assume that the interviewer heard the person correctly, understood what they were saying, and either remembered the words correctly or made accurate notes.

After the interviews have been conducted, the investigator should review documents and statements for:

• gaps in time

• inconsistencies

• contradictions

• missing evidence

• obvious omissions

The investigator may need to reinterview an individual or seek additional information. Depending upon the situation, the investigator also may need to continue the fact-finding process through a record review, observation, or examination. When all of the facts have been gathered, the administrator should perform a root cause analysis to assess whether the allegation or incident can or cannot be substantiated.

Finally, the investigator should assess the evidence for completeness and relevancy, and then weigh the evidence against the applicable legal or organizational standard before reaching a conclusion. If the outcome of an investigation requires employee corrective actions or termination, the administrator must follow corporate or facility policies and procedures on employee conduct as published.

By responding immediately to allegations or indications of employee misconduct, investigating thoroughly and fairly, and making informed conclusions, administrators can better safeguard their facility.

Linda Williams, RN, is Long-Term Care Risk Manager for the GuideOne Center for Risk Management’s Senior Living Communities Division. She previously served as Director of Nursing in a continuing care retirement community and as a nurse consultant for two corporations with numerous long-term care facilities in Iowa.

The GuideOne Center for Risk Management is dedicated to helping churches, senior living communities, and schools/colleges safeguard their communities by providing practical and timely training, and resources on safety, security, and risk management issues. For more information, call (877) 448-4331, ext. 5175, or e-mail at More information is available on the Center for Risk Management’s Web site at

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