Failure to Document Staff-to-Resident Abuse Allegation in Medical Record
Penalty
Summary
A deficiency was identified when the facility failed to ensure that an incident involving staff-to-resident abuse was completely documented in the clinical record for one resident. The resident, who had multiple medical diagnoses including moderate cognitive impairment, was involved in an incident where a CNA allegedly frightened her, removed her brief, and made threatening and derogatory statements. The incident was reported by an occupational therapist to the DON, and the facility initiated an investigation, including interviews with the resident, her family, and the CNA involved. Despite the investigation and multiple staff interviews confirming the expectation that such allegations should be documented in the resident's clinical record, a review of the resident's medical record revealed no documentation of the incident. Staff interviews confirmed that facility policy required allegations of abuse to be recorded in progress notes, including details of the event, statements from the resident, and the status of the resident. The absence of this documentation was acknowledged by both nursing and administrative staff during interviews. Facility policies reviewed indicated that nursing documentation should reflect all significant events, including allegations of abuse, to ensure accurate communication among the interdisciplinary team and to provide a complete picture of the resident's experience. The policy on abuse investigations also required review of pertinent records, such as progress notes, as part of the investigative process. The failure to document the abuse allegation in the clinical record constituted a breach of these policies and professional standards.