Failure to Assess and Notify Physician After Resident Abuse Allegation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who reported an allegation of physical abuse by another resident. On the evening of the incident, the resident informed a CNA that her roommate had hit her legs. The CNA relayed this information to an LVN, who then spoke with the resident and confirmed her complaint of pain in her legs. Despite this, there was no documentation that a body assessment was performed or that the physician was notified at the time of the allegation. Record reviews showed that the resident had a history of anxiety disorder, multiple sclerosis, and chronic pain syndrome, and was dependent on staff for several activities of daily living. The resident was cognitively intact and able to communicate her needs and experiences. The care plan and SBAR forms indicated that the resident was at risk for emotional distress related to the abuse allegation, but there was no evidence that an assessment or physician notification occurred immediately following the report of abuse. Interviews with nursing staff and the DON confirmed that facility policy required immediate assessment and physician notification in the event of an abuse allegation, which was not followed in this case. The facility's own investigative summary noted that staff failed to report the allegation because they believed the accused resident was not capable of such behavior. This failure to follow protocol resulted in a delay in care and monitoring for the resident who reported the abuse.