Failure to Investigate Resident's Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy by not conducting an investigation into allegations of physical and verbal abuse made by a resident against a CNA. The resident, who has diagnoses including flaccid hemiplegia, dysphasia, hypertension, and is dependent on staff for mobility and hygiene, reported that during a shower, the CNA used a hoist that caused pain to his private area, was rough, and made statements suggesting he had no rights. The resident's mother reported the incident to the Social Service Director, but no one from management spoke to the resident about the incident, and no investigation was initiated. Multiple interviews confirmed that the resident expressed discomfort and pain during the shower, and that he communicated this to the CNA, who did not reposition him or address his concerns. Other staff members and residents were aware of the resident's dissatisfaction with the CNA's care, and the resident's mother reiterated the details of the incident to facility staff. Despite these reports, the Social Service Director did not document the concern in the grievance book or speak directly to the resident, instead passing the information to the Administrator. The Administrator acknowledged that no investigation was conducted, no statements were collected from the resident or other staff, and the accused CNA was not suspended pending investigation. The facility's own policy requires immediate reporting, investigation, and protection of residents in such cases, including removal of the accused staff from resident contact. The failure to follow these procedures resulted in the deficiency cited by surveyors.