Failure to Implement Abuse Prevention Policy and Mandated Reporting
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident who sustained injuries of unknown origin. The policy required that all allegations or suspicions of abuse be promptly investigated, that the alleged victim be protected, and that the alleged perpetrator be suspended during the investigation. However, after an incident in which a CNA physically abused a resident, multiple staff members who were aware of the incident did not report it as required. The supervisor who was informed of the abuse did not initiate an investigation, did not report the incident to the administrator or the state agency hotline, and did not suspend the alleged perpetrator immediately. The CNA continued to work for several days after the incident before being suspended. Record review showed that the facility did not document or investigate the incident in its reporting log, and there was no evidence that the required screenings for abuse or neglect were completed with the CNA's prior employers or references. Staff interviews revealed that several staff members witnessed or were aware of rough and abusive behavior by the CNA toward multiple residents, including physical injuries and verbal mistreatment, but failed to act as mandated reporters. The facility's mandated reporter training attendance records indicated that not all relevant staff had received the required training. The facility had previously been cited for similar failures to protect residents from abuse, prevent further abuse, complete investigations, and report to the state agency. Despite staff being aware of their responsibilities as mandated reporters, they did not report the incidents, relying instead on supervisors who also failed to act according to policy and regulatory requirements.