Failure to Implement Abuse Prevention Policies Following Substantiated Abuse Incident
Penalty
Summary
A deficiency occurred when a staff member failed to implement the facility's abuse prevention policies and procedures for a resident who had multiple medical conditions, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The incident involved a Certified Nursing Assistant (CNA) who admitted to taking away the resident's room phone and placing it out of reach after the resident repeatedly called the front desk. This action was substantiated as abuse, as it resulted in the resident experiencing mental anguish. Interviews and record reviews revealed that, despite the facility's policy requiring ongoing abuse prevention training, staff did not receive additional abuse training following the incident. While some staff recalled completing annual abuse and neglect training, others could not remember when such training last occurred. The Director of Nursing acknowledged that ongoing abuse training should have been provided in response to the event, as outlined in the facility's policy, but this did not happen.