Failure to Thoroughly Investigate and Report Alleged Abuse Resulting in Bruising
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an allegation of abuse made by Resident 4. The facility’s Abuse Prevention and Prohibition Program policy requires prompt and thorough investigation and reporting of abuse, neglect, mistreatment, misappropriation of property, injuries of unknown origin, and criminal acts in accordance with federal and state requirements. Resident 4 reported to staff that two night-shift nurse aides grabbed her hands hard while providing incontinence care, resulting in bruises on both hands, and that the aides were laughing during care. Nursing documentation described bruising on the right dorsal hand near the thumb measuring 1.5 cm by 1.8 cm and a 2.0 cm by 2.0 cm bruise on the left dorsal wrist, both purple in color. Another nursing note recorded that the resident stated two girls at night grabbed her hard and left bruising on both hands and that this was reported to nursing administration. The facility completed an internal incident report that categorized the event as a skin incident and concluded the bruising was likely due to the resident being combative with care, based on statements from the two involved staff and one additional staff member who observed the resident being combative. However, there was no evidence that statements were obtained from other staff working on or near the unit at the time, from the resident’s roommate who was reportedly present, or from other residents cared for by the same employees to rule out potential abuse. Despite the resident’s allegation that staff grabbed her and caused bruising, the facility did not treat the event as an allegation of abuse and did not report it to the appropriate external agencies, including the Department of Health field office. The Assistant DON, Nursing Home Administrator, and DON acknowledged that they did not identify a need to report the incident as an abuse allegation and did not more thoroughly investigate it as such.
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