Failure to Protect Resident from Physical Abuse and Inadequate Investigation
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for toileting hygiene and had a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and osteomyelitis, reported being physically abused by a CNA during incontinent care. The resident described experiencing pain and fear after the CNA used a dry towel roughly on a healing labial skin tear, despite her requests to use wet wipes and to stop due to pain. The resident reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of her complaints or of a head-to-toe assessment being completed in response. The facility failed to implement protective measures, as the CNA continued to provide care to the resident after the initial complaint. There was no evidence that the CNA was suspended during the investigation period, and documentation in the CNA's personnel file did not reflect any suspension or disciplinary action related to the abuse allegation. Additionally, the care plan and physician orders did not address the labial skin tear, and there was a lack of documentation regarding the resident's complaints of rough treatment or any follow-up assessments. Interviews with facility staff revealed inconsistent awareness and response to the abuse allegation. The administrator did not investigate further, believing the incident did not constitute abuse, and did not document the allegation or conversations with the resident or CNA. Other staff members were either unaware of the complaint or could not recall details of the investigation or protective actions taken. The lack of prompt, thorough investigation and failure to remove the alleged perpetrator from resident care led to the identification of Immediate Jeopardy by surveyors.