Failure to Thoroughly Investigate Resident’s Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of physical abuse by a CNA toward a resident. Facility policy on abuse prevention and prohibition required that investigations include interviews with staff on all shifts who might have information about the alleged incident, interviews with staff on all shifts who had contact with the accused employee, and actions based on the information gathered. In this case, the facility’s investigation documented that the resident reported being pushed onto a bath chair, having a towel thrown at her, and being told to wash herself during shower assistance, and that she felt she had been physically abused. The social services director interviewed the resident and noted she initially appeared emotionally distressed and tearful, with a flat affect and guarded posture, and later concluded the resident was a poor historian with difficulty recalling long-term details. The investigation included an interview with the accused CNA, who denied the allegation and stated she had not provided care to the resident in a long time, but the report did not document the last date the CNA had been assigned to or assisted with the resident’s care. The facility concluded the allegation was unsubstantiated due to lack of corroborating evidence, inability to identify a specific timeframe, and findings they considered consistent with routine care. However, the investigation lacked documentation of interviews with other CNAs or nursing staff who worked with the resident to determine whether she had reported rough care or problems with showering assistance to others during the relevant period. It also lacked documentation of interviews with other residents to determine whether they had concerns about the CNA’s care. The investigation further failed to document any assessment of the shower area to identify environmental factors that might have contributed to the resident feeling abused, and did not include any attempts to observe or assess the CNA’s performance while assisting residents with showering and transfers. The resident, who had moderately impaired cognition, a history of knee injury, generalized weakness, falls, depression, anxiety, and insomnia, required assistance from one to two staff for transfers and bathing and had a behavior care plan that included monitoring behavior episodes and attempting to determine underlying causes. During a later interview, the resident reiterated that the CNA had been rough with her on more than one occasion, including pushing her onto the bath chair, throwing a wash cloth at her, telling her to wash herself, and telling her to put herself to bed, and she became visibly upset when recalling these events. The DON acknowledged that no additional investigation was done beyond what was documented in the facility’s investigation report.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.