Failure to Document and Assess Following Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that the investigation and medical record documentation were complete and accurate for a resident following an alleged incident of abuse by a Certified Nursing Assistant. The resident, who was cognitively intact and had a history of generalized muscle weakness, joint derangements, and pain, reported that a CNA handled her left arm roughly during care, resulting in pain that required a muscle rub. Despite this allegation, there were no progress notes or clinical assessments documented in the resident's medical record regarding the incident or the reported pain in the left arm/shoulder after the alleged event. Interviews with nursing staff revealed inconsistent understanding and application of documentation policies. Some LPNs stated they would document incidents or complaints in the resident's chart, especially if there was a change in condition or physical issue, while others were unsure if this was required by policy. The Assistant Director of Nursing and the Director of Nursing indicated that allegations without physical injury were not documented in the medical record, and that investigations were conducted before any charting occurred. Review of the clinical record confirmed that no assessment or monitoring was documented for the resident's left arm/shoulder following the allegation, and the only update was to the care plan for psychosocial monitoring. Facility policy required that a licensed nurse immediately examine any resident upon receiving reports of alleged physical or sexual abuse, with findings recorded in the medical record. The policy also mandated immediate reporting, investigation, and support for the alleged victim. However, the investigation report did not include an interview with the resident, and there was no evidence that a physical assessment was completed or documented as required by policy. The lack of documentation and assessment following the allegation constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.