Failure to Document Sexual Abuse Allegation in Clinical Record
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was completely and accurately documented in the clinical record. The resident in question had multiple medical diagnoses, including traumatic subdural hemorrhage, acute kidney failure, and moderate cognitive impairment as indicated by a BIMS score of 11. Despite a grievance being filed regarding a care issue involving a male CNA and the resident's care plan being updated to reflect a history of trauma and a preference for female caregivers, there was no documentation in the clinical record of the sexual abuse allegation. Interviews with nursing staff and the Director of Nursing confirmed that facility policy required documentation of abuse allegations in the clinical record, specifically in the progress notes. Staff acknowledged that such documentation should include details of the allegation, actions taken to protect the resident, and notifications made. However, the RN who received the report of sexual abuse did not document the incident in the clinical record, stating she was following instructions given to her. Policy review revealed that any incident should be charted every shift for 72 hours and then daily until resolved, and that changes in a resident's condition, including incidents or injuries, must be recorded in the medical record. Despite these policies, there was no evidence in the clinical record of the sexual abuse allegation for the resident, resulting in incomplete and inaccurate documentation.