Failure to Investigate and Protect Resident Following Allegation of Rough Care
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a female resident with a history of cerebral infarction, sepsis, diabetes, depression, anxiety, and sacral osteomyelitis, who was dependent on staff for toileting and incontinent of bowel and bladder, reported experiencing pain and fear after receiving rough incontinent care from a male CNA. The resident described the CNA using a dry towel during pericare, causing her significant pain and distress, and stated that her requests for gentler care were ignored. She reported the incident to multiple staff members, including a nurse and the social worker, but there was no documentation of a thorough investigation or immediate protective measures, such as suspension of the alleged perpetrator. The resident's care plan and physician orders did not address the labial skin tear that was identified, and there was no documentation of a head-to-toe assessment or follow-up regarding her complaints of rough treatment. Progress notes and incident reports lacked any mention of the resident's report of rough care or the labial tear, and the CNA continued to provide care to the resident after the initial complaint. Interviews with facility staff revealed inconsistent awareness of the incident, lack of documentation, and failure to follow facility policy, which required immediate reporting, assessment, and suspension of the alleged perpetrator during an investigation. The administrator, who was the designated abuse coordinator, did not document the allegation or her conversations with the resident and CNA, and did not initiate a formal investigation, stating she did not consider the incident to be abuse. The resident later recounted ongoing fear and distress, stating that the CNA continued to provide care after the initial incident and that she felt unsafe and traumatized. Interviews with the medical director and other staff confirmed that the use of a dry towel for pericare was not standard practice and that any complaint of rough treatment should have been documented and investigated. The facility's failure to document, investigate, and report the allegation, as well as to protect the resident during the investigation, constituted a deficiency and resulted in the identification of Immediate Jeopardy.