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Personnel investigations

October 22, 2009
by Linda Williams, RN
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How to protect your facility when allegations arise

Personnel investigations are necessary whenever there is an allegation or indication of employee misconduct. According to Federal Regulation F-225, “The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law through established policies.”

Clearly, it is every staff member’s responsibility to report any suspicion or indication of employee misconduct and in turn, it is administration’s responsibility to immediately follow up with an internal investigation. If either of these actions goes unheeded, the safety and security of both residents and the facility can be jeopardized. Please review the following situation and make changes as appropriate in your facility.

The situation

One evening, a newly hired CNA was asked to assist an elderly woman with her shower. The woman was frail and totally dependent upon staff to meet her needs, as she had a history of respiratory and heart disease, as well as severe dementia. She used a wheelchair for mobility and required the assistance of two staff members with all transfers. Additionally, she drank alcohol daily and often exhibited negative behaviors when staff attempted to care for her. Before starting the shower, the CNA searched for, but could not find, someone to help transfer the woman from her wheelchair to the shower chair. The woman was becoming agitated, so the CNA asked her to hang onto the grab bar in the shower room as she attempted to transfer her alone.

A background check came back indicating the CNA had previously been convicted of domestic violence, harassment, and theft.

As this was occurring, another CNA walked past the shower room door and heard a commotion inside. Upon entering the room, she found the woman on the floor with the new CNA beside her. The new CNA explained that the woman had begun to slip from her wheelchair, so she gently lowered her to the floor with the use of her gait belt so she would not get hurt. The second CNA asked the woman if she was all right, but the woman remained agitated and upset. There were no visible injuries, so the two CNAs assisted the woman with her shower and reported the incident to the charge nurse afterwards.

Upon hearing about the incident, the charge nurse checked the woman and later documented that she “saw no sign of injuries, however the resident complained of right knee pain, even though her knee was not bumped while being lowered to the floor.” The nurse gave the woman a mild pain reliever and reported the incident to the next shift nurse. During the night, the woman continued to complain of right knee pain and was given more of the pain reliever.

By the next morning, the woman was in excruciating pain and her right knee was considerably swollen. When the day shift nurse arrived, she quickly notified the woman’s physician and family of the situation. The physician ordered a stronger pain reliever and a portable x-ray of the injured site. When the x-ray results came back, it revealed that the woman had a fractured right femur, so she was sent to the hospital for treatment. Three days later, the woman returned to the nursing facility, but her condition had deteriorated to the extent that hospice services were requested and she died just days later.

Upon being notified of her death, the woman’s family complained to the state nursing home licensing bureau. In response, a survey was conducted that resulted in severe deficiency tags and a $10,000 fine for the facility. Some of the allegations included:

• Staff did not follow the woman’s care plans.

• Staff failed to notify the physician and family in a timely manner.

• Staff did not properly assess the resident or investigate the incident.

During the survey, the investigators interviewed key staff members. They discovered that a background check had been conducted before the new CNA was hired. However, the check came back indicating the CNA had previously been convicted of domestic violence, harassment, and theft, for which she subsequently completed anger management classes. Her personnel file reflected that she received a verbal reprimand for not following the woman’s plan of care, and nothing else.

All of the CNAs that worked the evening and night of the incident were additionally interviewed, including the aide who had helped to finish the woman’s shower. That CNA stated that during the shower, the woman seemed to cry out in pain a few times, but the new CNA always interrupted her by telling her “she was all right.” After the shower, the new CNA tried to talk her coworker out of reporting the incident to the charge nurse, but the coworker did it anyway. Other CNAs told the surveyors how that evening the new CNA joked about the incident and said she “would never care for that [derogatory name] again.”