Failure to Protect Resident and Conduct Thorough Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient protections and assessment following an allegation of staff-to-resident abuse, and failure to conduct a thorough investigation. A resident with non-Alzheimer’s dementia, depression, a psychotic disorder, moderately impaired cognition, disorganized thinking, unclear speech, and dependence on staff for all cares and transfers was allegedly subjected to verbal and physical abuse by a nursing assistant during evening cares. According to staff interviews, the nursing assistant spoke loudly, aggressively, and with profanity, telling the resident to hurry up and grab the bar and to walk to the bed, and stated that if the resident wanted to act like a child, she would be treated like a child. Staff reported that the nursing assistant used an open hand to smack the resident’s bare buttock, which sounded like a loud smack, while the resident was whining, whimpering, and making grunting sounds. The incident was reported by two staff members to the charge nurse on the evening of the alleged abuse. A trained medication assistant reported hearing the loud, aggressive, and profane language from outside the resident’s closed door and, after speaking with another nursing assistant who had been in the room, learned of the smack to the resident’s buttock. That nursing assistant also directly reported to the charge nurse that the staff member had been verbally aggressive and had smacked the resident’s right buttock. The charge nurse responded verbally but did not immediately contact the on-call nurse as required by facility policy, did not ensure the resident’s immediate safety, and did not initiate the required assessment and protective measures at that time. The resident’s medical record contained no documentation of a skin assessment or behavior assessment on the date of the incident, and there was no evidence of a documented skin check following the initial report of the allegation or the following day. The facility’s investigation process was also deficient. The alleged perpetrating staff member continued to work with residents for the remainder of the shift and into the next morning after the incident, and the allegation was not brought to the attention of supervisory nursing staff until the following day. When the investigation was initiated, the clinical coordinator interviewed a limited number of residents who were verbally responsive and in their rooms, totaling 11, and did not verify that skin checks or behavior chart reviews were completed for residents who could not be interviewed. Night staff who had worked with the accused nursing assistant, including the nursing assistant on the night shift with her, were not interviewed. The DON acknowledged that the charge nurse did not follow the facility’s maltreatment reporting guidelines, which required immediate reporting, suspension of the involved staff, and initiation of an investigation including resident and staff interviews, observations, and medical record review. The DON also acknowledged that resident skin monitoring and behavior chart review were not completed as expected, and that the facility’s policy was not followed by the charge nurse regarding communication of the incident and immediate protective actions.
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