Failure to Thoroughly Investigate Allegation of Rough Handling and Injury
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of rough handling and potential abuse involving one resident. The resident, who had dementia with behavioral disturbance, multiple cerebral infarctions, and weakness, required assistance of one staff member for bed mobility and toileting. On the date of the incident, a CNA assisted the resident with incontinence care and repositioning in bed. After being turned, the resident complained of right arm pain, reported hearing a snap, and rated the pain as 10/10. The resident told nursing staff that the CNA was rough and that the CNA pulled her arm while rolling her, causing pain. Following the incident, the CNA reported the resident’s complaint to an RN, who assessed the resident and noted that the resident was tearful and in significant pain when her elbow was touched. The CNA stated she had held the resident’s hand and hip to roll her and that the resident then said her arm hurt. The RN documented that the CNA acknowledged using the resident’s right arm to pull her toward the window to complete cares, and that the resident reported hearing a pop at the time the pain started. Another nurse (an LPN) also spoke with the resident and confirmed that the resident said the CNA was rough and had pulled her arm while rolling her, after which the resident heard a snap and experienced severe pain. EMS transported the resident to the ED, where the physician documented right elbow tenderness, a negative radiograph for fracture, and suspected a right elbow sprain. The facility’s abuse prevention policy requires that all alleged violations be investigated thoroughly, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and determining whether abuse or neglect occurred, its extent, and cause. Although the facility obtained statements from the resident, the CNA, the RN, and the LPN, there was no further documentation of the investigation beyond these statements and the ED report. The Nursing Home Administrator acknowledged that the facility did not interview other staff or other residents to determine whether there were additional concerns or a broader scope to the issue. Surveyors concluded that the facility failed to interview other residents and did not complete a thorough investigation of the allegation, resulting in the cited deficiency.
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