Failure to Implement Abuse Reporting and Resident Protection Policies
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policies after a resident reported being attacked and cursed at by a male nurse aide. The resident, who had intact cognition and a history of anxiety and depression, informed a female nurse aide during the night shift that a male staff member had attacked and cursed at her. The nurse aide reported this to a medication aide, whom she considered her supervisor, but did not escalate the allegation to the nurse, DON, or Administrator as required by facility policy. The medication aide stated that the resident only expressed a preference not to have a male aide and did not mention abuse, while the male aide involved denied any inappropriate behavior and was not immediately removed from the facility, remaining on shift with access to other residents. The facility's abuse policy required immediate reporting of all alleged violations to the Administrator and Adult Protective Services (APS), and immediate action to protect the alleged victim, including removal or suspension of the accused employee. However, the allegation was not reported to the nurse or administration until the resident's responsible party informed the Administrator the following morning. The accused aide was only removed from the schedule after the morning report, and there was no immediate assessment of the resident for injury or further risk during the night shift. Staff interviews revealed confusion about reporting protocols and a lack of direct communication to the appropriate supervisory personnel. Additionally, the facility failed to report the alleged sexual abuse to Adult Protective Services in a timely manner. Although the Administrator and social worker eventually contacted the Department of Social Services, this did not occur until several days after the initial allegation was made known to facility leadership. The delay in reporting to APS was confirmed by both the previous DON and Administrator, who acknowledged the requirement to notify APS promptly but did not do so as stipulated by policy.