Failure to Properly Investigate Resident’s Allegation of Rough and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policies and procedures after an allegation of verbal and rough physical treatment toward a resident. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial to maximal assistance with toileting, bathing, dressing, and transfers. The resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, and was mean, and that this interaction made the resident cry. In interviews, the resident described an incident in which the CNA roughly yanked the drawsheet from under the resident and threw it on the floor near the door, pulled out the resident’s brief, and grabbed and held the resident’s right arm straight up while the resident was attempting to fasten the brief tabs, which the resident typically adjusted independently. The resident stated that this occurred on a Sunday night, that the CNA’s behavior was rough and scary, and that the resident did not like what the CNA did. The resident reported the CNA’s bad attitude to the Social Services Director the following day. Record review showed that the facility’s investigation documentation was incomplete and did not comply with the written Abuse Investigation and Reporting policy. The Investigation Report lacked the name of the investigator, the names of all staff interviewed, the name of the resident involved, and the times of the interviews. The Administrator, DON, DHI, and DSD each acknowledged that the investigation report and CNA statement were missing required elements such as dates, times, resident and staff identifiers, interviewer name, staff phone number, and signatures. The DON and DSD stated that the investigation process outlined in the abuse policy was not followed and that the documentation was inaccurate, incomplete, and not considered a valid investigation report, despite the policy requiring thorough review of documentation, resident interviews, staff interviews on all shifts, and review of events leading up to the alleged incident.
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