Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by multiple incidents involving inappropriate and rough handling by certified nursing assistants (CNAs). Resident #699 reported that CNA Staff A was verbally abusive and physically rough during a shower, failing to follow proper hygiene procedures and leaving the resident feeling afraid and intimidated. The resident was not informed of the CNA's termination, leaving her in fear of potential retaliation. Resident #700 corroborated the account, describing the CNA's aggressive demeanor and improper care practices. In another incident, Residents #800 and #850 raised concerns about CNA Staff B's aggressive behavior. Resident #850 reported feeling intimidated and uncomfortable due to the CNA's rough handling and verbal aggression. Central Supply Staff D witnessed the CNA's inappropriate behavior and reported it to the nurse on duty. Despite these reports, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns rather than confirmed abuse. The facility's response to these allegations was inadequate, as there was no documentation of increased monitoring or protective measures for the affected residents. The Administrator acknowledged the need for improved customer service and staff education but did not provide evidence of effective measures to prevent future incidents. The lack of communication with residents about the outcomes of investigations contributed to their ongoing fear and discomfort.
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 (R899, 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 Rellas 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 or 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.