Failure to Conduct Thorough Abuse Investigation per Facility Policy
Penalty
Summary
The facility failed to implement its policy requiring a thorough investigation following an incident of abuse involving a certified nursing assistant (CNA) and a resident with intact cognition and a history of assaultive behavior. The incident occurred when the CNA took a cup of juice from the resident, prompting the resident to throw the juice at the CNA. In response, the CNA threw juice back at the resident, gestured with a disinfectant spray bottle as if to spray the resident, and made a confrontational statement. The CNA did not deny the incident, and the event was reported to supervisory staff and documented in the resident's records. Despite facility policy specifying that other cognitively alert residents should be interviewed to determine if there was a history of inappropriate staff behavior, no such interviews were conducted. The administrator and assistant administrator confirmed that no additional resident interviews were completed, and the DON stated that only the involved resident was interviewed, as they believed no other residents were present during the incident. The investigation did not include interviews with other residents who may have had contact with the CNA, contrary to facility policy.