Failure to Thoroughly Investigate Resident’s Allegation of Rough Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident, as required by its abuse policies and procedures. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial/maximal assistance with several ADLs, including toileting, bathing, dressing, and transfers. During an interview, the resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, yanked out the drawsheet from under her and threw it on the floor near the door, pulled out her brief, and grabbed and held her arm straight up while changing her, which the resident described as mean and causing her to cry. The resident stated she had reported the CNA’s bad attitude to the Social Services Director the day before the survey interview. The facility initiated an investigation documented on an Investigation Report dated 1/20/2026. That report reflected that another CNA stated the resident had told her that the CNA who took over the 3 PM–11 PM shift was rude, and that CNA 2 acknowledged taking over the resident’s care at 7 PM. CNA 2 reported that when she returned to change the resident, she rolled up and pulled out a dirty drawsheet, the resident grabbed and unrolled it, and food crumbs fell back on the bed; CNA 2 then took the drawsheet and left the room to look for the nurse in charge. The report also indicated CNA 2 informed an RN Supervisor that the resident had stated CNA 2 was being rough. However, the Director of Staff Development did not interview the resident after interviewing CNA 2 and CNA 3, explaining that the report was viewed as only involving pulling out the drawsheet and putting it on the floor. Record review and staff interviews showed that the investigation documentation was incomplete and inaccurate. The Social Services Director later acknowledged that the investigation conclusion was not accurate regarding which CNA the resident alleged was rough and that more in-depth follow-up interviews with the resident and involved staff should have been conducted. The DSD identified that CNA statements were incomplete or undated, missing the interviewer’s name, interview date, staff phone number, and staff signature, and stated that one CNA’s statement was not valid due to these omissions. The DSD also confirmed that the facility’s Abuse Prevention Program policy, which requires the investigator to record complete investigation results on approved forms and provide them to the Administrator, was not followed, as the investigation lacked essential information such as date and time, resident and staff involved, and the name of the interviewer/investigator.
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