Failure to Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete investigation into an abuse allegation involving Resident #117. This resident, admitted with neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, chronic pain syndrome, and Alzheimer’s dementia, had a BIMs score indicating severe cognitive impairment and required maximum assistance with toileting. A family member reported to police that an in-room camera showed a CNA kicking the resident’s bed, prompting police and family to come to the facility. The facility’s Self-Reported Incident noted the allegation and that the resident could not provide meaningful information due to dementia, and that no negative effects were observed at the time. However, the investigation file contained only a written statement from the accused CNA and a census sheet with check marks indicating residents felt safe, without documentation of individual resident responses or how non-interviewable residents were assessed. Further interviews revealed that staff who were present when police reviewed the video, including an RN Coordinator and another CNA, were not asked to provide witness statements. The DON confirmed she could not provide written evidence of staff interviews beyond the CNA’s statement or individual resident interview responses. The Medical Director did not recall being notified of the abuse allegation. The facility’s abuse policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be investigated, including interviewing the resident, the accused, and all witnesses, and documenting evidence of the investigation. These policy requirements were not met in the handling of the allegation involving Resident #117. The deficiency also includes the facility’s failure to investigate an injury of unknown source for Resident #47. This resident, with adult failure to thrive, paranoid schizophrenia, and dementia, had severely impaired cognition and was documented as having intact skin with no bruising to the extremities in a recent NP note. She was not on anticoagulant or antiplatelet therapy. During surveyor observation, a circular purplish-red bruise approximately the size of a half dollar was noted on her right forearm, which the resident could not explain. There was no nursing documentation of the bruise, no assessment, and no investigation in the record. The Regional Director of Clinical Services and the DON confirmed that staff had not documented or investigated the bruise, and an LPN acknowledged noticing the bruise but did not report it or complete any statements. The facility’s abuse policy defined injuries of unknown source and required immediate reporting and investigation of such injuries, which did not occur in this case.
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