Failure to Develop and Implement Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being physically abused by a Certified Nurse Assistant (CNA) during personal care. The resident, who had diagnoses of osteoarthritis and rheumatoid arthritis, was noted to have severe cognitive impairment and required maximal assistance with activities of daily living. Despite the resident's report of abuse to the Assistant Director of Nursing (ADON), a review of the resident's records confirmed that no care plan addressing the abuse allegation was created or implemented. Interviews with facility staff, including two Registered Nurse Supervisors (RNS) and the Director of Nursing (DON), confirmed that a care plan should have been developed following the abuse allegation to guide staff interventions and ensure the resident's safety. The facility's own policy required care plans to be updated when there is a significant change in a resident's condition, but this was not done in response to the reported abuse. This omission resulted in a failure to deliver necessary care and services as required.