Failure to Document Assessment and Actions Following Abuse Allegation
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one resident following allegations of rough handling and sexual abuse. The resident, who had multiple diagnoses including metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction, and hypertension, was assessed as having severely impaired cognitive skills. An incident was reported involving allegations of sexual misconduct by a staff member, and while a skin assessment was documented, there was no documentation in the clinical record regarding a physical assessment or actions taken in response to the allegations. Interviews with staff revealed that a registered nurse performed a thorough assessment of the resident, including the genital area, and reported the incident to the DON, administrator, physician, and police. However, neither the nurse nor the DON documented these actions in the resident's clinical record. The administrator and former DON confirmed that the required documentation was missing, with the DON stating that the nurse should have entered the assessment and actions into the electronic health record, but this was not done. The only documentation related to the incident was found in the investigation file, not in the resident's clinical record.