Failure to Investigate and Document Resident Grievance of Rough Handling
Penalty
Summary
The facility failed to properly investigate a complaint of mistreatment involving a resident who was cognitively intact and required maximal assistance for toileting hygiene due to multiple medical conditions, including malignant neoplasm of the cauda equina, COPD, neuromuscular bladder dysfunction, and anxiety disorder. The resident's family member reported to facility staff that the resident had been handled roughly by a CNA during incontinence care. Despite this report, there was no documentation in the resident's chart regarding the complaint, the reporting of the incident, or any follow-up actions taken by staff. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), RN Case Manager (CM), and Director of Staff Development (DSD), revealed that none of them conducted interviews with the resident or the CNA involved regarding the alleged rough handling. The SSD and CM acknowledged that they did not document the complaint or any follow-up actions. The DSD confirmed that no one spoke to the CNA about the incident, and no disciplinary counseling, education, or in-service was conducted in response to the complaint. The facility's policy required that all grievances or complaints be investigated, documented, and responded to both verbally and in writing, with a written summary provided to the resident or their representative. However, the facility did not follow these procedures, as there was no investigation, documentation, or communication of findings to the resident or family. The only action taken was to remove the CNA from working with the resident, without any formal investigation or staff education.