Failure to Thoroughly Investigate Allegation of Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse by a CNA toward one resident. The resident, who had a history of cerebrovascular accident (CVA), hallucinations, and a BIMS score of 9 indicating moderately impaired cognition, was re-admitted shortly before the incident. The admission MDS indicated the resident had no documented behaviors. On the date of the incident, the resident completed an Individual Statement Form describing that while standing beside the bed to get into the wheelchair, the CNA moved the wheelchair to face the door and placed both hands firmly on the resident’s shoulders. The resident stated the CNA did not punch, slap, or shove, denied pain or discomfort, and did not believe the CNA intentionally tried to cause harm, but did not want to work with that CNA. The facility’s Reportable Event Record/Report documented that the resident told therapy staff that the CNA “hit” the resident while attempting to move back into the wheelchair, then clarified that the CNA put hands on the shoulders in a strong manner and denied being struck. The DON assessed the resident with no untoward findings, and statements were obtained from the resident and the CNA. The COTA/L and PT documented that the resident reported being in the room trying to scoot back in the chair when the CNA “hit” the resident, later clarifying that the resident was not used to being touched like that and did not want to return to the current room if that caregiver would be there. An OT email further recorded that the resident used the word “hit” to describe the motion, stated it was not hard and did not cause pain, but that the resident was startled, upset, and unwilling to go back to the room if that caregiver was present. The CNA’s written and verbal statements denied any inappropriate touching or hitting and indicated that after repositioning the wheelchair, the resident made no comments or complaints. During the surveyors’ review of the facility’s investigation, there was no evidence that other residents or additional staff beyond the reporting staff and the CNA involved were interviewed. The Administrator confirmed that only residents and staff directly involved or around the area of the incident were interviewed and acknowledged there were no other resident or staff interviews. This practice did not follow the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, which requires that all allegations be thoroughly investigated, including interviews with the person reporting, any witnesses, the resident, staff on all shifts who had contact with the resident during the period of the alleged incident, the resident’s roommate, family members, visitors, and other residents to whom the accused employee provides care or services.
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