Failure to Protect Residents from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by two separate incidents involving a certified nurse aide (CNA). In one incident, a CNA was witnessed physically abusing a resident with Parkinson's Disease and Dementia, who had moderately impaired cognition. The CNA grabbed the resident's nose and twisted it, causing bleeding, and made a derogatory comment. In another incident, the same CNA verbally threatened a different resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, by stating she would beat the resident if she soiled the bed again. Both incidents were witnessed by other CNAs. Despite these events, the staff members who witnessed the abuse did not immediately report the incidents to the nurse, DON, or Administrator. The witnesses cited fear of retaliation and concerns about job security as reasons for not reporting. As a result, the Administrator was not informed of the allegations until ten days after the initial incident, leaving the residents and others vulnerable during that period. Interviews with additional staff revealed that the CNA in question was known to speak to residents in an aggressive or angry manner, but this behavior was dismissed by some staff as part of her personality and not reported to management. The facility's own policy required immediate reporting and action in cases of abuse, but this was not followed. The delay in reporting and lack of immediate protective action allowed the CNA to continue working with vulnerable residents, placing them at risk for further harm. The deficiency was identified through interviews, record reviews, and the facility's internal investigation, which substantiated the abuse allegations based on staff witness statements.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, Minimum Data Service nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee met to review the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of abuse.
- The Staff Development nurse started education with licensed nurses, CNA's and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements and 100% has been completed.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements and that failure to do so is a crime.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.