Failure to Protect Resident from Abuse and Inadequate Response to Allegation
Penalty
Summary
A cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia reported being physically and verbally abused by an agency CNA during the night. The resident described being roughly handled, punched in the back multiple times, threatened, and intimidated by the staff member, who also instructed her not to use the call light. The resident was left feeling unsafe and distressed, ultimately leading her to discontinue her rehabilitation and request discharge home. The incident was not immediately reported to the resident's family or physician, and the resident's family only learned of the abuse when visiting later that day. Facility staff, including an RN and the LPN night supervisor, failed to conduct or document any physical or psychosocial assessment of the resident following the allegation of abuse. Both staff members acknowledged in interviews that no assessment was performed to determine if the resident had sustained injuries. Additionally, there was no documentation of efforts to notify the resident's family or physician about the incident, and no interdisciplinary notes reflected any follow-up assessment or intervention for the resident's well-being after the alleged abuse. The facility also failed to ensure proper screening and training of agency staff. The human resources director stated that agency staff records and training were not reviewed or maintained by the facility, and no documentation was provided to demonstrate that the agency CNA involved in the incident had been appropriately screened or trained in abuse prevention and reporting. The facility's own policy required prompt investigation, assessment, and reporting of abuse allegations, but these procedures were not followed in this case.