Failure to Immediately Report and Respond to Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its written abuse policy when an allegation of physical abuse was made involving a resident with vascular dementia, anxiety, delirium, and severely impaired cognition. The incident occurred when a CNA was observed by another CNA to have roughly pulled the resident's arms off a hallway rail and pushed her into a chair. Despite the allegation, the accused CNA was not immediately removed from resident care and continued to work the remainder of the shift. The incident was not reported to the Abuse Coordinator or the State Agency immediately as required by facility policy. The resident involved had a history of aggressive behaviors and impaired communication, making her particularly vulnerable. The care plan noted her potential for physical aggression and refusal of medications, and she was known to be verbally aggressive due to dementia. On the night of the incident, the resident refused a head-to-toe assessment and was unable to be properly interviewed due to her cognitive status. The staff member who witnessed the alleged abuse left a written statement for the DON at the end of the shift, as administrative staff were not present at the time. Interviews with staff revealed that the LVN on duty did not report the allegation to the Abuse Coordinator as required, and both the accused CNA and the LVN continued their duties until the following day. The facility's policy required immediate protection of the resident and notification of the appropriate authorities, but these steps were not followed. The failure to act promptly and according to policy resulted in non-compliance and placed residents at risk of further abuse.