Failure to Investigate and Protect Residents After Allegations of Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed and to protect residents after allegations of rushed, harsh, and physically abusive care by a nursing assistant were reported. Multiple residents described ongoing inappropriate behavior and treatment by the nursing assistant, including being handled roughly during care, experiencing pain, and being subjected to demeaning or condescending remarks. Despite these complaints, there was no documentation of a comprehensive investigation, no identification of the residents involved in the initial written warning, and no evidence that follow-up with affected residents was completed. Interviews with residents revealed specific concerns about the nursing assistant's conduct, such as being moved too quickly or roughly during transfers, causing pain, and making residents feel anxious, worthless, or angry. Some residents reported avoiding care from the nursing assistant or refusing showers due to discomfort. Staff interviews confirmed that concerns about the nursing assistant's behavior had been reported to facility leadership, but there was no indication that these reports led to a formal investigation or protective measures for the residents. Facility records showed that the nursing assistant continued to work with all residents until the state agency brought the allegations to the attention of the administrator. The facility's own abuse prevention policy requires immediate notification of the administrator, documentation, investigation, and protective actions when abuse is alleged. However, the facility did not follow these procedures, as there was no evidence of resident assessments, witness interviews, or separation of the accused staff member from residents during the investigation period.