Failure to Monitor and Document Resident After Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was assessed and monitored for 72 hours following an alleged incident of physical abuse, as required by the facility's policy and procedure. The resident, who had diagnoses including adult failure to thrive, dementia, and weakness, was dependent on staff for most activities of daily living and had moderately impaired cognitive skills. After an alleged episode of physical abuse by a certified nurse assistant, the care plan was updated to include regular assessment of the resident's emotional status. However, a review of the medical records revealed that there was no documentation of monitoring for the resident's condition during all shifts on the day following the incident. Interviews with nursing staff and facility leadership confirmed that 72-hour monitoring and documentation should have been completed for each shift, especially given the resident's inability to verbalize changes in condition. The facility's policy required licensed nurses to document the resident's status every shift for at least 72 hours after a change in condition, but this was not done. The absence of monitoring and documentation was acknowledged by multiple staff members, including the Director of Nursing, who confirmed that the required assessments were not performed as per policy.