Failure to Identify, Investigate, Report, and Protect After Allegation of Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, report, and implement protective measures in response to an allegation of abuse, as required by its Abuse Prohibition Policy and Procedures. The policy stated that staff must identify events that may constitute abuse, immediately remove the alleged perpetrator from duty pending investigation, initiate an investigation within two hours, protect patients during the investigation, and report allegations of abuse to appropriate agencies within specified time frames. Despite these requirements, when a family member reported that a CNA had handled a resident roughly during incontinence care and requested that the CNA not be reassigned, the facility did not treat this as a potential abuse allegation and did not follow the policy’s mandated steps. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as well as essential hypertension, and was documented as cognitively intact with capacity to understand and make decisions. Staffing records showed that the CNA in question was assigned to the resident on consecutive shifts. A change in condition evaluation documented that the resident claimed the CNA was rough while turning him, and that the supervisor was made aware and the CNA was reassigned for the remainder of that shift. However, there was no indication that the incident was reported to the Administrator or DON as the abuse coordinator, and no immediate investigation or protective measures consistent with the abuse policy were initiated at that time. Interviews further substantiated the allegation and the facility’s failure to act in accordance with its policy. The family member reported that the resident said the CNA hurt his left arm and that a roommate, who was alert, confirmed hearing the resident scream during care. The resident later stated that the CNA pulled him by his left arm, causing pain, and that he screamed but the CNA did not stop or respond. The roommate reported hearing the resident say “you hurt me” while the CNA continued care and appeared to be in a hurry. Despite the family member’s request that the CNA not be reassigned, staffing records and interviews confirmed that the CNA was again assigned to the resident on a subsequent night shift, and the Administrator stated she was not informed of the complaint and that the CNA should not have been reassigned pending investigation. The CNA reported that no one interviewed her or explained why she had been reassigned on the day of the complaint, further demonstrating that no timely investigation or protective process was initiated as required by the facility’s abuse policy.
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