Failure to Thoroughly Investigate and Report Alleged Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough investigation of an allegation of physical abuse toward a resident and to ensure appropriate administrative review and reporting. Facility policy required that all abuse allegations be promptly and thoroughly investigated, with information collected to corroborate or disprove the incident and findings reviewed by the Administrator and grievance officer. A resident with vascular dementia, major depressive disorder, anxiety disorder, severe cognitive impairment (BIMS 03/15), and requiring assistance with ambulation was allegedly slapped or tapped on the buttocks by an LPN while at the nurses’ station wearing only a brief under a gown that was open toward the dining area. CNA interview documentation indicated the LPN smacked the resident’s brief, the resident stated, “I don’t like that,” the LPN did it again, and the resident raised a fist and repeated that she did not like it, while the LPN laughed. The DON later characterized the action as a playful tap done in fun and determined there was no intent to harm. Despite this allegation and the facility’s own policy, the investigation was incomplete and not properly escalated or reported. The resident’s electronic medical record contained no documentation of the incident or any follow-up investigation, and incident reports at admission did not include the alleged event. The facility did not perform or document a physical exam, skin assessment, or psychosocial assessment of the resident after the incident, and there was no indication that the investigation findings were reviewed by the Administrator or grievance officer. The Executive Administrator stated she was unaware of the allegation until informed by the surveyor, and confirmed the allegation had not been reported to the State Survey and Certification Agency as required by Federal and State law. The DON acknowledged that the incident was not reported externally because she concluded it was playful and without intent to harm.
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