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F0607
D

Failure to Remove Alleged Abuser from Resident Care During Abuse Investigation

Washington, District Of Columbia Survey Completed on 05-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to implement their written policies and procedures for investigating incidents of abuse for one of eight sampled residents. According to the facility's policy, when an abuse allegation is made, the alleged abuser must be removed from resident care pending the investigation. However, documentation and staff interviews revealed that the certified nurse assistant (CNA) accused of being verbally rough with a resident continued to work and provide care to the resident during the investigation period. The incident involved a resident with multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, and major depressive disorder, who was assessed as having intact cognition and requiring extensive assistance for daily activities. The resident reported that a CNA was verbally rough and handled her belongings in a manner she found upsetting. The facility's investigation included statements from the CNA, the former Director of Nursing (DON), and interviews with other residents, but the CNA remained on duty and assigned to the resident throughout the investigation. A review of assignment sheets and timesheets confirmed that the CNA continued to work on the unit and care for the resident during the period in which the abuse allegation was being investigated. Both the current DON and the CNA acknowledged in interviews that, according to facility policy, the staff member should have been removed from resident care during the investigation, but this did not occur.

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