Failure to Thoroughly Investigate Resident Allegation of Rough Care by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of mistreatment as required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires an immediate investigation of any suspicion or report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation. Despite this, the facility did not conduct a comprehensive investigation after a resident reported concerns about how two CNAs provided ADL care, and the facility did not interview any other residents to determine if there were broader concerns about care. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. He was dependent on toileting hygiene and transfers, required substantial/maximal assistance for rolling, was always incontinent of urine, and had a colostomy. On New Year’s Day, he reported to the Surveyor that two female staff entered his room around 2:00 a.m. to change him; he stated he told them he was not wet, but they insisted on changing him, that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief, and that he told them he did not have dementia and did not need this care. He further stated he reported to the nurse that staff had “roughed him up” and held his wrists down, and that the nurse did not respond. A nurse’s note dated 1/1/26 at 06:12 by an RN documented that the resident wanted to see the nurse during the night shift, complained about the two night CNAs who performed ADL care, and wanted the issue reported. The RN notified the DON and was authorized to have the CNAs write statements, which were placed under the DON’s door. In interviews, the RN confirmed he reported the incident to the DON. The DON acknowledged being notified that the resident did not want to be changed and that she had CNA statements, and described the situation as the resident becoming belligerent, striking out at staff, and refusing care. However, the DON stated she did not talk to the resident, did not conduct an investigation, did not interview the CNAs beyond obtaining their written statements, and did not obtain a statement from the RN. The NHA also reported not conducting any investigation. As a result, the facility lacked evidence of a thorough investigation of the resident’s allegation, and no resident interviews were conducted to identify any additional concerns about care.
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