Failure to Initiate Change of Condition Assessment and Monitoring After Abuse Allegation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for one of three sampled residents. A resident made an allegation of physical abuse by a CNA, which was reported to the charge nurse. Upon assessment, the resident was found to have a skin tear on the left forearm and reported pain. The incident was reported to the RN Supervisor, who notified the DON, Administrator, and police, and wound care was provided. Despite the facility's policy and procedure requiring a change of condition assessment and monitoring every shift for 72 hours following such incidents, the medical record review revealed that this assessment was not initiated for the resident after the allegation of abuse. Progress notes documented some monitoring, but there were missing entries for specific shifts, and no formal change of condition assessment was completed. Interviews with nursing staff and the DON confirmed that the assessment should have been completed and that the incident constituted a change in condition per facility protocol. The failure to initiate the required change of condition assessment and consistent monitoring as outlined in the facility's policy had the potential to result in the resident not receiving appropriate care and monitoring to prevent complications or delayed medical treatment related to the abuse allegation. The DON and staff acknowledged these findings during interviews and record reviews.