Failure to Thoroughly Investigate Alleged Abuse and Delay in Reporting
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident and a CNA, as required by its Abuse, Neglect, and Exploitation policy. The policy mandates immediate investigation of suspected abuse, identification and interviewing of all involved persons, complete and thorough documentation, and protection of residents from harm during and after investigations. The facility’s written procedures also require prompt reporting of all alleged violations to the administrator and state agencies within specified timeframes, and immediate actions to protect the alleged victim and other residents. The resident involved had a Brief Interview for Mental Status score of 9, indicating severely impaired decision-making skills, and a Patient Health Questionnaire score of 6, indicating mild depression. The resident had no upper extremity range of motion impairment, bilateral lower extremity range of motion impairment, and was independent with eating, dressing, and mobility, requiring supervision for showers and set-up for transfers. On the date of the incident, a CNA (CNA-D) reported that another CNA (CNA-E) referred to the resident using derogatory language, handled the resident’s food with bare hands, ran fingers through the food, and spat on the food on the lunch tray, stating an intention to watch the resident eat it. CNA-D stated that the resident ate the food and that CNA-E later commented, “Guess what? She ate it,” and indicated an intention to “mess with” the resident again the following day. The facility submitted a mistreatment, neglect, and abuse report the day after the incident, documenting that CNA-D observed CNA-E spit on the resident’s food and reported the incident to an LPN (LPN-F), and that the administrator was notified that same day. However, the surveyor determined that LPN-F learned of the allegation near the end of the first shift (which ends at 2:30 PM) and did not immediately report it to the administrator, allowing CNA-E to remain in the facility and continue working in resident care areas until 8:45 PM. The facility’s investigation consisted only of verbal interviews with CNA-D and CNA-E, did not include a statement from LPN-F beyond whether the incident was witnessed, and failed to document the time the incident occurred or the time the allegation was reported to the administrator. The administrator acknowledged the surveyor’s concern that the allegation of abuse was not thoroughly investigated, and no additional information was provided to explain the incomplete investigation.
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