Failure to Immediately Protect Resident Following Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to immediately protect a resident from alleged staff-to-resident physical abuse after the resident reported that staff were rough during repositioning. The resident, who had diagnoses including rheumatoid arthritis, chronic pain syndrome, and fibromyalgia, and was cognitively intact, reported to the DON that night shift staff were rough with them. The DON treated the report as a grievance related to care rather than an abuse allegation, and did not immediately suspend the staff involved or initiate an abuse investigation at that time. The staff members identified in the allegation continued to work in the facility and were not suspended until several days later, after the hospital notified the facility of the abuse allegation made by the resident's family. Facility policy required immediate action to protect residents from harm and to suspend alleged perpetrators pending investigation. Despite this, the staff members named in the allegation continued to work in the facility between the initial report and the later notification from the hospital, although they did not work directly with the resident during that period. The deficiency was identified through staff interviews, record reviews, and policy review, and was found to affect one resident reviewed for abuse.