Failure to Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect residents from potential abuse after an allegation of physical abuse was reported against a medication aide (MA). The incident involved a male resident with severe cognitive impairment, including dementia, psychosis, and anxiety disorder, who was alleged to have been punched in the chest by the MA after the resident kicked her. The incident was witnessed by another resident's family member, who reported it to the former Assistant Director of Nursing (ADON) several days later. The former ADON did not report the allegation to the Administrator, nor did he suspend the MA from resident contact, but instead reassigned her to a different unit. Despite the family member's concerns and explicit request that the MA not work on the secured unit, the MA continued to work in the facility and was later assigned again to the same unit as the resident involved in the alleged abuse. The MA remained in contact with residents, including the alleged victim, until the family member reported the incident directly to the Administrator nearly a month later. The facility's own policies required immediate reporting of abuse allegations to the Administrator and suspension of the accused employee from resident contact pending investigation, but these procedures were not followed by the former ADON. Interviews and record reviews confirmed that the MA worked multiple shifts after the initial allegation was made and that the former ADON did not escalate the report as required. The Administrator stated that she was not informed of the incident until much later and that the MA should have been suspended immediately. The facility's policies and regulatory guidance clearly outlined the need for immediate action to protect residents and report allegations, but these were not adhered to, resulting in a period where residents were at risk for further abuse.