Failure to Implement Abuse Prevention Policy and Timely Skin Assessment
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after an incident in which a resident alleged mistreatment during a shower, the facility did not perform or document a timely skin assessment as required by its abuse policy. The policy mandates that an immediate assessment and documentation in the medical record occur upon discovery of alleged abuse, but this was not completed following the resident's allegation. The resident involved had a history of chronic skin conditions and was moderately cognitively impaired. She had refused showers previously and required a two-person assist for bathing. On the day of the incident, two CNAs assisted with her shower, during which the resident became upset and alleged that she had been scrubbed too hard and that both hot and cold water were used. Staff interviews confirmed that no skin assessment was documented on the day of the incident, and the only available assessment was completed two days later without specifying its relation to the allegation. Interviews with nursing staff and administration revealed that the required documentation and assessment were not completed at the time of the incident. The DON and ADON acknowledged that the lack of immediate assessment and documentation was a failure to provide adequate care and ensure continuity. The facility's own policy was not followed, as the assessment and documentation were either delayed or omitted, placing residents at risk for abuse and neglect.