Failure to Implement Abuse Prevention Policy and Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and did not take appropriate actions to protect a resident from abuse by an LPN. On the morning of the incident, the LPN was observed by a CNA placing a paper towel over the resident's nose and pinching it, while also covering the resident's mouth, in an attempt to force the resident to swallow medications. The resident, who had a history of severe cognitive impairment and multiple medical diagnoses including acute respiratory failure, dementia, and cerebrovascular disease, was left alone with the LPN after the CNA witnessed the event. The CNA did not immediately intervene or report the abuse, instead leaving the room and only reporting the incident to the DON several hours later. Despite the facility's policy requiring immediate suspension of any employee accused of abuse and immediate reporting, the LPN continued to work and administer medications to residents during the survey period, placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and the LPN was allowed to return to work after a brief suspension. The facility's failure to recognize and act upon the abuse allegation resulted in the LPN maintaining access to residents for over a month after the incident. Interviews with staff revealed a lack of timely reporting and intervention in response to the witnessed abuse. The CNA who observed the incident did not follow the facility's abuse policy for protecting residents, and other staff members did not take immediate action when informed of the situation. The facility's leadership, including the DON and Administrator, acknowledged that the abuse policy was not followed and that the resident was not adequately protected from potential harm.