Failure to Thoroughly Investigate Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of abuse involving one resident with severe cognitive impairment and dementia. The resident was non-interviewable per a recent MDS, and was observed to be pleasantly confused. An incident file contained an unsigned word-processed statement attributed to an LPN describing an event in which a CNA tapped the resident on the head, yelled “Stop,” taunted the resident, pushed the resident’s hands down, laughed, and told the resident that nobody cared about her after she said she would report him. This document lacked basic investigative elements such as the date of the incident versus the interview date, the identity of the interviewer, and whether the interview was conducted in person or by phone. The statement also did not capture the full extent of the alleged verbal abuse and physical interaction later described by the LPN in a surveyor interview. In a subsequent phone interview with the surveyor, the LPN provided a more detailed account, stating she was a new employee and that upon entering the resident’s room she saw the CNA hit the resident on the head, yell “Stop,” retrieve the resident’s communication whiteboard, get in the resident’s face, taunt her, grab her hands, and push them down. The LPN reported that the resident said she would report the CNA to the state, and that the CNA laughed and said, “go ahead, nobody care about you.” The LPN stated she was very uncomfortable with the CNA’s aggressive treatment, remained with the resident because the resident was afraid and upset about being hit, and then reported the incident to another nurse, who told her the administrator had to be notified. The LPN stated she relayed the same chain of events to the administrator that she later described to the surveyor, but this level of detail and the alleged verbal abuse were not reflected in the facility’s written incident documentation. The CNA’s written statement, in contrast, was on a facility form that included the name and position of the person interviewed, the interviewer, the date of the interview, the date of the incident, and the location. In that statement, the CNA acknowledged tapping the resident on the head to get her attention and admitted he could have chosen to tap her shoulder or arm instead. He acknowledged the resident said she would report him and that he told her to stop saying that, but he did not document any verbal abuse. In a phone interview with the surveyor, the CNA again admitted hitting the resident on the head, denied responding when she said she would report him, and stated he learned of allegations of physical and verbal abuse from the administrator after being suspended. The administrator, however, denied awareness of any verbal abuse allegation, could not explain discrepancies between the LPN’s and CNA’s documentation, and offered no explanation for why the LPN’s interview was on an unsigned word document while the CNA’s was on a completed facility form. The facility’s abuse policy required comprehensive interviews of the resident, accused, and witnesses, with written, signed, and dated statements, but there was no documentation showing a complete investigation into the alleged verbal abuse, the CNA’s tone or intent, or whether his “go ahead” comment was abusive or encouraging of the resident’s rights, and no past non-compliance document was created for this incident.
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