Neglect and Mental Abuse in Resident Care
Penalty
Summary
The deficiency involves the failure of a facility to protect residents from neglect and mental abuse, as evidenced by the experiences of four residents. Resident #699 reported that a CNA was verbally abusive and rough during care, failing to follow proper hygiene procedures and threatening to leave the resident unattended. The resident expressed fear and anxiety due to the CNA's behavior and was not informed promptly about the CNA's termination, which prolonged the resident's distress. Resident #700 corroborated the account of Resident #699, describing the CNA as intimidating and rough during care. The resident witnessed the CNA's inappropriate handling of Resident #699 and reported the incident to the facility. Despite the facility's investigation, the CNA's behavior was deemed inconsistent with facility standards, leading to her termination. Additionally, Residents #800 and #850 raised concerns about another CNA, Staff B, who displayed aggressive behavior and was rough during care. Resident #850 reported being left uncovered and in a soiled state for an extended period, feeling demeaned and hurt by the CNA's actions. The facility's investigation into these allegations was inconclusive, but due to concerns about customer service, CNA Staff B's employment was terminated.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R699, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by . 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed by . Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Relias during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or . With any allegation of neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.