Failure to Thoroughly Investigate Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse reported by a cognitively intact resident with multiple diagnoses, including bipolar disorder, anxiety, depression, morbid obesity, chronic pain, and arthritis. The resident required varying levels of assistance with activities of daily living and reported that a nursing assistant was rough and rude during dressing care, resulting in shoulder pain and emotional distress. The resident's care plan identified her as a vulnerable adult and directed that any suspicions of abuse or neglect be investigated. Upon review, the facility's documentation was incomplete. The grievance form related to the incident was not fully filled out, with key sections such as the summary of investigation, conclusion, corrective actions, and required signatures left blank. There was no evidence in the medical record that a nursing or body/skin assessment was conducted after the allegation, nor was there documentation of monitoring the resident for issues related to the incident. Interviews with facility staff revealed that only a limited number of interviews were conducted, and there was a lack of documentation for these interviews. No additional staff or residents were interviewed to determine if there were broader concerns regarding the care provided by the accused nursing assistant. The facility's own policies required a thorough investigation of all allegations, including reviewing documentation, interviewing all relevant parties, and documenting the investigation completely. However, the investigation was not completed as required, and there was no evidence that staff were educated regarding the concerns raised by the allegation. The failure to follow established protocols and to document the investigation process resulted in a lack of thoroughness in addressing the resident's report of rough care.