Failure to Assess and Document After Abuse Allegation
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow professional standards of practice after a resident's family member reported an allegation of abuse. The family member informed the nurse that the resident had stated someone was hitting her at night. The resident, who had a history of severe cognitive impairment as indicated by a low BIMS score, was unable to provide further details about the alleged incident during an interview. Despite the report, there was no documentation that a complete skin assessment was performed or that the findings were recorded using the facility's SBAR communication tool, as required by policy. The resident involved had multiple medical conditions, including a recent fracture, aphasia following a cerebral infarction, hypertensive heart disease, chronic kidney disease, and a history of falls. The resident's cognitive status was severely impaired, making it difficult for her to communicate details about the alleged abuse. Staff interviews confirmed that the resident was often confused, emotional, and frequently cried, but no prior signs or symptoms of abuse had been observed by the staff. Interviews with the DON and Administrator revealed that their expectations were for the nurse to ensure the resident's safety, perform a thorough skin assessment to check for signs of abuse, and document the assessment in the EMR using the SBAR format. However, both the DON and Administrator were unable to locate any documentation of such an assessment or SBAR note in the resident's record. The facility's policy required detailed observation and documentation in the event of a significant change in a resident's condition, which was not followed in this case.