Failure to Immediately Investigate and Protect Resident After Alleged Involuntary Seclusion
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of abuse involving a resident who was reportedly barricaded in the nurses' station by a CNA. On the night in question, a CNA was observed by another CNA with a resident positioned at the CNA desk, with a treatment cart placed in such a way that the resident could not freely leave the area. The CNA explained that the resident was placed there because they had been entering other residents' rooms. When the observing CNA moved the treatment cart, they were able to take the resident for toileting and observed blood and bruising on the resident's leg, which was reported to a nurse and attributed to a previous fall. Despite the report of possible involuntary seclusion, which is considered a form of abuse according to the facility's own policy, the CNA accused of the action was not immediately removed from resident care or placed under supervision. The CNA continued to work several shifts after the initial allegation was reported to both the DON and NHA. The facility did not initiate a full investigation or suspend the CNA until a week after the initial report, when the concerns were raised again by another staff member. Staff interviews and documentation confirmed that the facility's leadership was aware of the allegation but chose not to act immediately, citing their belief that the incident did not occur as described. The facility's abuse prevention policy requires immediate action to protect residents and a thorough analysis of the occurrence, but these steps were not taken in a timely manner. The resident involved had a history of falls, and at the time of the incident, was found with a skin tear and bruising on the leg.