Failure to Enforce Abuse Prevention Policy Resulting in Resident Exposure to Alleged Perpetrator
Penalty
Summary
The facility failed to enforce its own abuse prevention and reporting policies for a resident with dementia and multiple chronic medical conditions, including VTE, CKD, fibromyalgia, and spinal stenosis. On one occasion, a CNA was witnessed by another CNA forcefully and aggressively handling the resident while assisting her to the commode, including manhandling her by the armpits and slamming her onto the commode. The incident was observed to be an act of misconduct due to rough handling, as confirmed by the Director of Risk Management and Regulatory Affairs. Despite the facility's policy requiring immediate suspension of employees suspected of abuse to protect residents, the CNA involved continued to work several shifts after the incident. The DON acknowledged that the CNA should have been suspended the same day as the incident, and that the delay left the resident exposed to potential further abuse. The facility's Code of Conduct and abuse prevention policies, which require residents to be treated with care and respect and mandate suspension of suspected employees, were not followed in this case.