Failure to Report Abuse Allegation and Complete Pre-Employment Screening
Penalty
Summary
Staff failed to implement and follow the facility's abuse policy regarding the immediate reporting of abuse allegations and employment screening requirements. On one occasion, several employees witnessed the DON and a CNA physically restrain a resident against a wall, search the resident's pockets, and pry open the resident's hand in an attempt to retrieve medication. Despite multiple staff witnessing this physical altercation, none reported the incident immediately to the Administrator or DON, and the event was not brought to their attention until four days later. The SUD Counselor, who witnessed the end of the altercation, acknowledged not reporting the incident until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations. The resident involved had a history of alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and PTSD. The resident was alert, oriented, and able to make needs known, with an activated health care proxy prior to admission. During the incident, the resident was agitated, uncooperative, and resisted being held, repeatedly telling staff to leave them alone. The altercation ended after staff removed a lighter from the resident's pocket, and the resident was subsequently sent to the emergency department for evaluation due to combativeness and uncertainty about medication ingestion. Additionally, the facility failed to conduct required background checks prior to employment for two staff members. The CNA involved in the incident began working at the facility over two months before a CORI check was completed, and there was no documentation of a Massachusetts Nurse Aide Registry check for the SUD Counselor prior to employment. The Administrator confirmed that these checks should have been completed before the staff began working, as required by facility policy.