Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood according to her MDS. On the day of the incident, the resident became verbally aggressive and was observed by multiple staff members to be resisting redirection away from a door. A certified nurse aide (CNA) intervened by forcefully hooking her arm under the resident's arm, turning her around, and walking her down the hallway despite the resident's resistance. Several staff members reported that the CNA appeared angry, used inappropriate language, and that the resident was dragged down the hallway while fighting and yelling. Witnesses, including a registered nurse (RN), a licensed practical nurse (LPN), and another CNA, expressed discomfort with the CNA's actions and described the interaction as aggressive and inappropriate. Despite these observations and statements, the facility's initial abuse investigation was incomplete. The CNA involved was suspended immediately after the incident but was allowed to return to work after the investigation was deemed unsubstantiated. The administrator confirmed that not all witnesses present during the incident were interviewed, including a CNA who directly intervened and took over care of the resident. Additionally, other staff members present on the hallway at the time were not interviewed as part of the initial investigation. The administrator admitted to not being concerned due to a lack of prior issues with the CNA, which contributed to the incomplete investigation. The facility's failure to follow its own abuse and neglect policy, which requires a thorough investigation including interviews with all relevant staff and witnesses, resulted in the CNA returning to work with the resident and other residents before the investigation was properly completed. This failure to protect the resident from further potential abuse and to conduct a comprehensive investigation led to an Immediate Jeopardy finding by surveyors.
Removal Plan
- Administrator, DON, and ADON reviewed Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.
- Staff were educated on Abuse Prevention Policy by DON and ADON.
- Staff not working dayshift were called by Administrator, DON, and ADON and were given education via phone of Abuse Prevention policy.
- Remainder of the staff not working or reached by phone will be required to receive the education prior to working their next shift by DON and/or ADON or designee and will be required to sign the education sign-in sheet.
- An Emergency QAPI (Quality Assurance Performance Improvement) discussion was held with Medical Director, Administrator, DON, ADON and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit for thorough investigation will be conducted with each allegation investigation. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meeting.
- Administrator and DON will meet monthly to review all audit findings and discuss, if any, possible further training/education or policy review changes need to occur.
- R1's Care Plan was updated with at risk for abuse/harm and interventions by Social Service Director.