Failure to Immediately Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure the immediate removal of a Certified Nurse Aide (CNA) from resident care following an allegation of physical abuse involving a resident with dementia, psychotic disturbance, and anxiety disorder. The incident occurred when the CNA did not adhere to the resident's Comprehensive Care Plan, which required two staff members to be present during behavioral episodes. This resulted in a skin tear on the resident's hand. Despite the incident being documented in an accident report, the CNA was allowed to continue working until the end of their shift, contrary to the facility's policy on abuse prevention and investigation. The deficiency was further compounded by a lack of timely communication and action from the Nursing Supervisor, who failed to report the incident to the Administrator or Director of Nursing immediately. The incident was only discovered during a daily review of reports, leading to a delay in the suspension of the CNA. The facility's investigation substantiated the abuse allegation, and the CNA was eventually terminated. However, the initial failure to remove the CNA from resident care and report the incident promptly constituted a breach of the resident's right to be free from potential abuse.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assist with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The abuse Reporting and investigation policy was reviewed on 2/10/2025 with no changes. Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee