Failure to investigate abuse allegation and protect cognitively impaired resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse and to protect a resident from potential further abuse after the allegation was reported. The facility’s abuse policy required that all alleged or suspected incidents of abuse, neglect, mistreatment, or misappropriation of resident property be thoroughly investigated, with findings documented and reported, and that residents be protected from abuse. Resident #1, who had non-Alzheimer’s dementia, muscle weakness, difficulty walking, and severely impaired cognition per the most recent MDS, was the subject of the alleged abuse. Video surveillance from the unit on the date of the incident showed Resident #1 ambulating with an unsteady gait, using hallway handrails, and then rolling a cart with personal protective equipment into two residents’ rooms. Certified Nursing Assistant (CNA) #1, who was pushing another resident up the hallway, followed Resident #1 into a room, rolled the cart back into the hallway, and was then seen pulling Resident #1 by the arm into the hallway. CNA #1 held Resident #1 under the left armpit and pulled the resident up the hallway toward their wheelchair while the resident resisted. CNA #1 then seated Resident #1 on the edge of the wheelchair; as the resident resisted sitting, CNA #1 held the resident under the armpit and by the pants and dragged the resident fully back into the wheelchair. CNA #1 then pushed the resident’s upper body forward while their right hand moved back and forth at the resident’s lower back, appearing to hit the resident on the buttock, with the resident’s body jerking forward. A visitor for another resident was observed in a nearby doorway looking toward CNA #1 and Resident #1, and the visitor and CNA #1 appeared to exchange words and hand gestures. Later that day, the visitor reported the incident to the Director of Nursing (DON). The facility’s undated internal summary of the incident documented that the visitor demanded discipline for CNA #1 due to a verbal altercation and described hearing a commotion, coming out to observe, and asking CNA #1 what they were doing with Resident #1. The DON stated in interview that the visitor only reported rudeness by CNA #1 and did not report rough handling or hitting. The DON reviewed the video footage but stated they did not identify CNA #1’s actions as abusive or excessively rough and, based on CNA #1’s denial, did not further investigate the matter as abuse. CNA #1 was suspended for one day for poor customer service and then reassigned to another unit, but was not removed from resident care or access to residents in response to an abuse allegation, and no thorough abuse investigation was initiated at that time. Registered Nurse Supervisor #1 reported that the DON informed them that a family member had complained that CNA #1 was cursing at them after they questioned what CNA #1 was doing with Resident #1. The DON told the supervisor that video review showed CNA #1 attempting to put Resident #1 into their wheelchair and instructed the supervisor to perform a body assessment on Resident #1. The supervisor stated that they and the DON assessed Resident #1 and found no redness, discoloration, or visible injury, and that the resident was smiling and in good spirits with no complaints of pain or discomfort; however, this assessment was not documented in the resident’s chart, and the physician was not notified. There was no documented RN assessment of Resident #1 related to the alleged incident, and the attending physician later stated they were not made aware of any allegation of rough handling or abuse involving Resident #1 until more than a week after the event. The facility did not initiate a formal abuse investigation until after the state surveyor’s onsite visit, during which it was confirmed that CNA #1 had continued to work on other units after the date of the alleged abuse.
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