Failure to Enforce Abuse Resolution and Care Assignment Restrictions
Penalty
Summary
The facility failed to follow through on the resolution of an abuse allegation involving a resident with dementia, psychosis, anxiety disorder, and narcolepsy. The resident, who had moderate cognitive impairment and required substantial to maximal assistance for daily care, reported feeling unsafe and expressed a preference not to be cared for by a specific CNA. Following an investigation, the facility informed the resident that this CNA would no longer be assigned to provide his care, and the resident was satisfied with this outcome. Despite this resolution, electronic documentation showed that the same CNA continued to provide care to the resident on multiple occasions after the agreement was made. Interviews with staff revealed a lack of awareness regarding the restriction, and the CNA continued to work in the area where the resident resided. The facility's policy required leadership to implement guidelines prohibiting mistreatment, neglect, and abuse, but these measures were not effectively communicated or enforced in this case.