Failure to Update Care Plan and Implement Monitoring During Abuse Investigation
Penalty
Summary
The facility failed to follow its policy and procedure for resident abuse in the case of one resident. After an allegation was made that a Certified Nurse Assistant (CNA) hit the resident on the buttocks and thighs while assisting with dressing, the resident expressed concern that the incident could recur if not reported. The Director of Nursing (DON) confirmed that, during the investigation, no interventions were added to the resident's care plan, and enhanced monitoring was not implemented as required by facility policy. Record review showed that the resident had a history of depression, paraplegia due to a self-inflicted gunshot wound, and left-sided weakness. The facility's policy stated that during an abuse investigation, actions such as assessment, care planning, supervision, staff assignment, and monitoring should be taken to ensure the resident's health and safety. The DON acknowledged that the care plan was not updated or revised following the incident, and the required monitoring was not put in place during the investigation process.