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F0610
D

Failure to Protect Resident from Potential Abuse During Investigation

Davenport, Iowa Survey Completed on 07-16-2025

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

The facility failed to ensure resident protection from potential abuse by allowing an alleged perpetrator to return to work before the initiation and completion of a state agency investigation. A resident with severe cognitive impairment, including schizophrenia, non-Alzheimer's dementia, and anxiety, reported that a night shift CNA did not assist with dressing or toileting. The resident's BIMS score indicated severe cognitive impairment, and she required substantial staff assistance for toileting and hygiene. Following the allegation, the CNA was initially suspended, but was reinstated the same day after the resident changed her description of the staff member involved multiple times. Despite the ongoing investigation by the state agency, the CNA resumed providing care to the resident and continued working subsequent shifts. The facility's policy required protection of residents from potential harm during and after investigations, including measures such as staff suspension and increased supervision. However, the facility reinstated the CNA based on the resident's inconsistent statements before the state agency had completed its investigation, resulting in a failure to fully protect the resident from potential abuse as required by policy.

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