Failure to Thoroughly Investigate Alleged Abuse and Assess Resident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light again. The CNA also refused to provide her name when asked. The nurse notified the administrator, who directed the CNA to leave the facility immediately. Although a body check was reportedly done with no injuries noted, there was no documented physical or psychosocial assessment of the resident after the incident, nor were efforts made or documented to reach the family, physician, or medical director at that time. The administrator did not interview or obtain statements from all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members who were working during the CNA's shift were not interviewed, and only residents from different units were interviewed as part of the internal review. The staffing agency manager confirmed that the CNA was simply blocked from future shifts but was not interviewed or reported to the CNA registry. The interim DON was not informed of the incident or involved in the investigation, despite being responsible for oversight of the nursing staff. Facility policy requires that all reports of abuse be thoroughly investigated, including interviews with all relevant staff, witnesses, and other residents who may have been affected, as well as a physical and psychosocial assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and documentation was incomplete regarding the resident's condition and notifications to appropriate parties.