Failure to Immediately Suspend Staff After Alleged Abuse
Penalty
Summary
The facility failed to ensure residents were free from potential abuse by not immediately suspending a staff member after an allegation of staff-to-resident abuse. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including a history of stroke, hypertension, chronic kidney disease, glaucoma, blindness in one eye, osteoarthritis, diabetes, and dementia. The resident required significant assistance with daily activities and was known to be resistive to care. The deficiency occurred when a housekeeper reported witnessing a CNA forcefully apply deodorant to the resident's arm against his wishes and then spray deodorant in his face after the resident became agitated. The housekeeper immediately reported the incident to an LPN, who continued passing medications for five to ten minutes before addressing the concern. The LPN did not immediately assess the resident, waiting approximately ten minutes, and found no signs of distress or injury. The DON was informed later and instructed the LPN to switch the CNA's assignment but did not suspend the CNA upon learning of the alleged abuse. The facility's policy required immediate removal of staff suspected of abuse from resident care areas, but this was not followed. The CNA was not suspended until several hours after the allegation was reported, and the LPN and housekeeper were also suspended later in the day. The investigation included interviews and assessments, and the allegation was ultimately unsubstantiated, but the delay in removing the accused staff member from resident care constituted the deficiency.