Failure to Assess and Monitor Resident After Alleged Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a resident after the resident alleged that a staff member handled her roughly during care. The resident, who was admitted with contractures of the left elbow, wrist, and hand and had documented capacity to understand and make decisions, reported that during the night a CNA slammed her left arm on the bed while attempting to wake her for a brief change. Record review showed no documented evidence that the resident was assessed following this incident for injury, pain, or emotional distress, and no evidence that any monitoring or interventions were initiated in response to the allegation. The RN Supervisor stated she became aware the morning after the incident that the resident reported the CNA was rough during care and acknowledged this should have been treated as a change of condition. She stated the resident should have been assessed and monitored, but no assessment or monitoring was completed. The DON similarly stated that licensed nurses were expected to complete a change of condition assessment, notify the physician, and perform assessment and monitoring when a concern is identified, and confirmed that this was not done for this resident after the alleged incident. The facility’s “Notification of Changes” policy required informing the resident and consulting with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
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