Failure to Ensure Dignified Care and Proper Response to Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignified care and proper handling of abuse allegations for two residents. One resident (R1), with essential hypertension, COPD, bipolar disorder, muscle wasting, unsteadiness, lack of coordination, a history of falls, moderate cognitive impairment, and limited upper extremity range of motion, was totally dependent for all ADLs except eating and required significant assistance with toileting and wheelchair use. R1 reported to the Social Service Director (V4) and her county case manager (V7) that a night-shift CNA, described by physical characteristics, was rough with her care, including during transfers from bed to standing and perineal care, and that she was afraid the CNA would be rough again. V4 observed bruises on the backs of both of R1’s arms, asked about their origin, and was told by R1 that a night CNA had been rough with her care, while V7 noted small, faded bruises on both forearms and R1’s report of a neck pull during transfer. A second resident (R3), cognitively intact with an upper extremity range of motion impairment and orders for a left arm sling and ongoing occupational therapy, required substantial/maximal assistance with upper and lower body dressing. R3 filed a grievance that a night-shift CNA was on her phone during care, was rude, and rough with care. R3 later stated that the CNA belittled him by calling him lazy and saying he did not need help, and that he reported this to nursing and therapy staff. An LPN (V16) confirmed that R3 reported the CNA was on the phone, belittling him, and rough with care, and stated she immediately informed the Director of Nursing. Despite these reports, the facility did not appropriately treat the allegations as potential abuse. For R1, although V4 acknowledged the allegation of rough care and stated it would be reported to the Administrator and investigated as possible abuse, the report documents that the concern was logged as a grievance related to staff approach and resolved the same day, without further detail of an abuse investigation in the cited findings. For R3, V4 documented the concern as a grievance about staff approach and contacted the CNA directly on her personal cell phone to address phone use, but did not report or investigate the allegation of rough and belittling care as potential abuse. V4 stated she did not consider the situation abuse because she knew the CNA personally and believed she was a good person, and she informed the DON only about phone use. Facility leadership, including the Interim Administrator/Abuse Prevention Coordinator (V1) and the DON (V2), later confirmed they were not aware of R3’s grievance and that the allegation was not reported or investigated as potential abuse.
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.