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F0607
D

Failure to Protect Resident After Witnessed Abuse Incident

W Concord, Massachusetts Survey Completed on 05-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse witnessed a certified nurse aide (CNA) slap the left side of a resident's face with an open hand. The resident involved had severe cognitive impairment. After witnessing the incident, the nurse left the resident and the accused CNA alone in the room and immediately went to report the incident to the nurse manager, rather than intervening or ensuring the resident's immediate safety by separating them from the alleged perpetrator. The facility's abuse policy required staff to report any signs of abuse immediately and to protect residents from harm during investigations, including reassigning or suspending the accused staff member to prevent further contact with residents. Interviews confirmed that the nurse did not intervene or remain with the resident after witnessing the alleged abuse, and the director of nursing acknowledged that the nurse should have stayed with the resident and asked the CNA to leave. The failure to follow the facility's abuse policy and procedures resulted in the resident, who was cognitively impaired, being left alone with the staff member accused of abuse immediately after the incident.

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