Every incident, whether it involves a crime, an accident, or a natural disaster, leaves traces of evidence at the scene.  The goal of every investigation is to correctly identify the facts, reconstruct the events and deduce what occurred.  When possible illegal activity is identified, the “crime scene” can be one of the most important sources of information for the investigation.    It is therefore critical that facility staff recognize when an incident or allegation rises to the level of a reportable incident and/or a possible crime, and the necessity to respect the scene and protect any available evidence.

While nursing facility staff are not forensic investigators, they must recognize that there are invaluable clues at the scene of every incident.  Identifying and documenting the presence of these clues can help in determining the “root cause” of a fall, or in establishing if a crime may have occurred.   In order to perform this identification and documentation, there must be preservation of the crime scene.

In the UNODC (United Nations Office on Drugs and Crime) manual “Crime scene and physical evidence awareness for non-forensic personnel” it is explained that:

Preservation of the scene and its evidence aims at implementing appropriate protective and contamination measures to keep disturbances of the scene and the physical evidence to a minimum.  Scene preservation starts as soon as possible after the incident is discovered and reported to the appropriate authorities. Concerns for scene protection end only at the point where the scene investigation process is completed and the scene is released.[i]

Important steps for preserving the scene include the following:

      • First and foremost, if the incident involves a resident, the resident must receive any necessary care and treatment and be protected from any further harm. This must be done carefully, disturbing as little of the environment as possible.
      • Determine the area to be protected, and cordon it off using whatever barriers are available, and keep non-essential people out of the area.
      • Anti-contamination measures should be implemented to the extent possible, including the use of gloves, protective clothing and shoe covers; using a single path for entering and exiting the scene; and avoiding moving anything unless absolutely necessary. If something is moved, documentation should include the original location.

Documentation is the next vital step in the crime scene preservation process.  The UNODC indicates:

Documentation aims at producing a permanent, objective record of the scene, of the physical evidence and of any changes that take place. (Id.)  Documentation at the scene is also the starting point for the chain-of-custody, which refers to the “process of maintaining and documenting the handling of evidence and involves the keeping of a detailed log showing who collected, handled, transferred, or analyzed evidence during an investigation.”[ii]

A variety of methods can be used to effectively document, including notes, photography, videos, sketches and measurements, depending on what works best for the incident scene.  The UNODC describes the following as essential items to include in the documentation:

      • Arrival time
      • Status of doors, windows and shades
      • Odors
      • Signs of activities
      • Any person present at, entering, or leaving the scene and any changes that take place as a result of activity undertaken or observed.
      • Once physical evidence is recognized, detailed documentation is made before it is moved or recovered. Each recovered item is labelled individually.

While no one anticipates that they may encounter a crime within their facility, facility staff education should include the possibility that they may be called upon to recount certain details and demonstrate actions taken during any potential crime scene investigation.  This might involve questioning by the facility investigator, a surveyor, a police investigator, or an attorney in a court of law.  Documentation is crucial to recall and demonstrate the status of the scene of the incident and the key evidence regarding what took place.

In most circumstances, if a crime is suspected and reported to law enforcement in accordance with the regulations, the police and/or professional investigators will arrive at the facility quickly, and take over the scene preservation and investigation.  However, in the event that there is any delay in their availability, or in situations where the facility is making their initial evaluation of the incident and has not yet determined if a crime is suspected, crime scene preservation will be crucial.  In addition to being knowledgeable on reporting possible abuse, neglect, misappropriation or other potential crimes, facility staff must understand the significance of respecting the crime scene.

Join Proactive on February 14 as we continue the 2023 webinar series Deep Dive into Federal Regulations in a Year with a comprehensive discussion of §483.12 Freedom from Abuse, Neglect, and Exploitation. Complimentary access to the on-demand recording of the January session §483.10 Resident Rights Requirements is available with the full series purchase.

Contact Proactive LTC Consulting for assistance in conducting investigations, implementing plans of correction or for Legal Nurse Consulting services.

[i] Crime Scene and Physical Evidence Awareness for Non-Forensic Personnel. UNODC (2009). https://www.unodc.org/documents/scientific/Crime_scene_awareness__Ebook.pdf

[ii] https://legaldictionary.net/chain-of-custody/



Written By: Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting


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