Failure to Timely Investigate and Separate Alleged Abuser Following Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and did not separate the alleged perpetrator from residents in a timely manner. A resident with severely impaired cognition, requiring substantial assistance with showering and diagnosed with Alzheimer's, non-Alzheimer's dementia, and anxiety disorder, was involved in the incident. According to staff interviews and documentation, a CNA intentionally sprayed the resident with cold water during a shower, despite protests from other staff present. The resident reacted by yelling, screaming, and attempting to stop the action, while the CNA laughed and continued for 10-15 seconds. Two CNAs witnessed the event and told the perpetrator to stop, but the incident was not immediately reported. The facility's policy required immediate measures to prevent further potential abuse, such as suspending the employee, and prompt investigation and reporting to the State Agency. However, records show that the CNA continued to work several shifts after the incident before any action was taken. There was no documentation that the alleged abuser was separated from residents or that an investigation was initiated prior to several days after the event. The deficiency centers on the facility's failure to respond appropriately and promptly to an alleged violation of abuse policy.