Failure to Protect Resident During Abuse Investigation
Penalty
Summary
A deficiency occurred when the facility failed to take immediate steps to protect a resident from further potential abuse during an ongoing investigation. The incident involved a resident with multiple diagnoses, including Parkinson's disease, dementia, and mood disturbances, who was moderately cognitively impaired and required assistance with toileting. During a night shift, the resident was observed to have fallen, become restless, and subsequently urinated on the floor after requests for assistance were ignored by a nurse aide. The nurse aide was reported to have become agitated, yanked the resident's wheelchair, and made derogatory remarks to the resident in the presence of others. Multiple staff interviews confirmed that the nurse aide displayed aggressive and inappropriate behavior towards the resident and other staff, including yelling, cursing, and refusing to provide care when requested. The LPN on duty reported the incident to the RN supervisor, but the supervisor did not take immediate protective action or remove the nurse aide from the unit. Instead, the supervisor advised the staff to resolve their issues or take them to Human Resources, and did not escalate the report of potential abuse or ensure the safety of the resident. The Director of Nursing later confirmed that she was unaware of the full extent of the incident until prompted by surveyor inquiry and acknowledged that the facility's policy required immediate removal of staff accused of abuse. The facility's own policy mandates immediate protection of residents and removal of alleged perpetrators during investigations, but this was not followed, resulting in a failure to protect the resident from further potential harm while the investigation was ongoing.