Failure to Remove Accused CNA After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy to protect all residents from abuse when a resident alleged that a CNA physically abused them. After the resident reported to the Nursing Supervisor (NS) that the CNA pulled their arms and punched them, the NS reassigned another CNA to care for the resident but did not remove the accused CNA from the unit. The CNA continued to provide care to other residents and had access to the resident who made the allegation until the end of the shift. The resident involved had multiple diagnoses, including heart failure, bipolar disorder, depression, anxiety disorder, and a pelvic fracture. The resident was assessed as cognitively intact and able to communicate clearly. The incident was reported to the NS, who obtained statements from the involved staff and reassigned the CNA but did not send the CNA home or remove them from the unit, contrary to facility policy. The DON later confirmed that the expectation was for the accused staff member to be sent home pending investigation, which was not done in this case. Documentation and interviews confirmed that the CNA remained on the unit and continued to care for other residents after the abuse allegation was made. The facility's policy required immediate removal of staff accused of abuse to protect residents from further harm during investigations. The failure to follow this policy resulted in the accused CNA maintaining access to the resident and others, which was identified as a deficiency and resulted in an Immediate Jeopardy situation.
Removal Plan
- Assessment of Resident #2
- Completion of the investigation
- Resident #2's care plan was updated for two-person care
- Re-education provided to CNA #1
- Re-education provided to NS #1
- Education was provided to all staff on the facility abuse policy and procedures for resident protection
- Alert and oriented residents on CNA #1's assignment were interviewed to rule out unreported allegations
- All residents with a Brief Interview for Mental Status (BIMS) score of 9 or above were interviewed
- Non-alert and oriented residents on CNA #1's assignment and throughout the facility had skin assessments completed