When you became a long-term care Administrator or Director of Nursing you probably didn’t envision that you would also wear the hat of a detective.  In today’s long-term care environment, being able to conduct a thorough internal investigation is a critical strength for all administrative staff.  From the report of a missing item, an accident or incident, to an allegation of abuse, each day presents situations requiring an understanding of the steps of a comprehensive inquiry and review process.

Timing the Investigation

No matter the reason for the investigation, it should generally begin immediately after the event/situation is reported or as soon thereafter as possible.  The more time that passes, the more likely it becomes that any critical evidence or “environmental cues” will have been removed or relocated, preventing access to the information they could provide.  For example, if an incident occurs involving a fall, any equipment involved, spills in the area, or furniture that may have caused a hazard will most likely be moved or cleaned up to allow access for assessment and first aid of the person involved.  If the first witnesses on the scene are not immediately identified and then interviewed, key observations providing insights into the “root cause” of the event might be missed.  Also, the more time that passes after the event, the more difficult it is for witnesses to remember the critical details.

If the situation involves a reportable event, the staff with that responsibility must make sure it is done within the required timeframe.  Delays in the staff reporting of the event to the designated team member will shorten the amount of time available for the initial investigation and fact-gathering before the deadline for reporting occurs.  In the case of a missing item, a delay in the reporting of this event could prevent the ability to search for and locate the item.  This then results in the need to report a potential “misappropriation allegation” when it might be a simple matter of being misplaced instead.

For non-abuse-related investigations that involve past issues not immediately impacting resident safety, additional preparation time may be acceptable to review any relevant records and develop an understanding of the potential scope of the issue in order to develop an investigation plan.  By way of example, a report of someone upcoding or falsifying payroll time may require time to review data and record-keeping in order to develop an understanding of the scope of the potential issue.  Nonetheless, the investigation should be initiated promptly.

The Interview Process

Interviews are an essential component of a thorough investigation.  The use of a pre-set short list of questions for staff or residents to answer cannot possibly reveal all of the facts and details that are needed to thoroughly evaluate an event.  Many times, an interview answer can lead to a new, totally different question, or to many follow up questions that will help to clarify a sequence of events.  Quite often a follow up interview may be needed, after everyone else has been interviewed the first time.  Information provided in the first round of interviews may reveal new evidence that requires a new set of questions, or identifies additional people that need to be interviewed.

Interview techniques that can be very successful include asking open ended questions, requesting a re-enactment of the events, or the use of diagrams or pictures to help interviewees explain the circumstances.  When using these techniques, however, the interviewer must be aware that the diagrams, pictures or descriptions that are documented may be producible in a court proceeding, and must be protected in case of this event.  It is often best to consult with the facility legal counsel before completing any documentation of this type.  It is also helpful to ask if there is anyone else that the interviewee suggests you should speak to relative to the event in question.

A timely and thorough internal investigation is a critical element to preventing survey deficiencies and potential litigation.  Join us on July 6th and & 7th for more tips and strategies in the next webinar of the Cultivating LTC Leaders series:  Internal Investigations.


Blog by Janine Lehman, RN, RAC-CT, CLNC, Proactive Medical Review

Learn more about Janine and the rest of the Proactive team.