Failure to Thoroughly Investigate Alleged Abuse and Assess Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment, Alzheimer's disease, Parkinsonism, and bipolar disorder. On the date of the incident, a certified nurse aide barricaded the resident in their room by stuffing washcloth wipes in the door, preventing it from opening. The incident was discovered by housekeeping staff, who found the resident inside the room, calm and watching television. The resident was then cared for and brought to the dayroom. The facility's investigative summary noted that video footage was reviewed to identify the staff member involved, but the footage was not saved or made available for surveyor review. There was no documented evidence that the resident was assessed for injury by a registered nurse, physician, or nurse practitioner following the incident. Additionally, not all staff present on the unit at the time of the incident were interviewed, as the administrator relied on video footage to determine who to interview and stated it was not facility policy to interview all staff. The administrator also indicated that video footage is not routinely saved and was unable to provide it to surveyors, citing a lack of knowledge on how to copy the footage.