Failure to Investigate and Document Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of rough care and treatment for one resident. The incident involved a cognitively intact female resident who required maximum assistance with transfers and had a care plan indicating the need for one staff member to assist with toileting and transfers. The resident's family reported concerns that an agency CNA provided rough care during toileting, specifically stating the CNA pushed the resident down onto the toilet and was rough when wiping. The family reported the incident to a staff member, who then informed the DON. However, there was no documentation of a formal investigation, and the facility's grievance records did not reflect the complaint. Interviews revealed inconsistencies in staff responses and actions. The CNA scheduler, who was informed of the incident by the family, reported the matter to the DON but did not directly notify the Administrator. The DON stated she did not consider the incident to be abuse, did not interview the resident or the CNA involved, and was unable to produce any documentation or notes regarding the incident, stating that any notes had been shredded. The DON also did not report the incident to the Administrator, as required by facility policy. The Administrator only became aware of the incident after being questioned by a surveyor and confirmed that no investigation had been initiated prior to surveyor intervention. The facility's policy requires all reports of abuse, neglect, or mistreatment to be thoroughly investigated and documented, with findings reported to appropriate agencies. In this case, the facility did not follow its own policy, as there was no evidence of a thorough investigation or documentation of the incident involving the resident. The lack of investigation and documentation could place residents at risk by failing to address and resolve allegations of abuse or neglect.