Failure to Protect Resident from Abuse Due to Delayed Reporting and Inaction
Penalty
Summary
A severely cognitively impaired resident, fully dependent on staff for care due to conditions including epilepsy and spastic quadriplegic cerebral palsy, was not protected from abuse by facility staff. During care, a Certified Nursing Aide (CNA) was alleged to have smacked the resident while the resident was soiled, and another CNA who witnessed the incident did not immediately report the suspected abuse. Instead, the witnessing CNA waited approximately 45 minutes to an hour before notifying the Director of Nursing, during which time the alleged abuser continued to provide care to the resident. Additionally, a Registered Nurse (RN) became aware that the resident was visibly upset and had a tear in their eye after being yelled at by the same CNA. The RN questioned the CNA, who admitted to yelling at the resident, but the RN did not immediately report this information to a supervisor or intervene to remove the CNA from caring for the resident. The RN later stated that she was alarmed by the situation but only reported it after being asked by the Unit Manager, who denied being informed about the yelling incident at that time. The facility's abuse policy required immediate action to protect residents from harm and prompt reporting of suspected abuse. However, both the CNA and RN failed to follow these procedures, resulting in the resident remaining in the care of the alleged abuser after the incidents of physical and verbal abuse. The delay in reporting and lack of immediate protective measures constituted a failure to protect the resident from further abuse, as required by facility policy.
Removal Plan
- CNA #2 was removed from resident care and suspended pending investigation and was terminated.
- The local police were notified.
- The facility started investigating the incident.
- Resident #1 was assessed.
- The facility reported CNA #2 to the NJDOH on the FRIDAY form and the Health Care Professional Responsibility and Reporting Enhancement Act.
- RN #1 was individually counseled and provided with remedial training.
- The facility's Abuse Prevention Policy was updated and redistributed to all staff to include termination for failure to report in a timely manner.
- Quick reference posters for abuse reporting were installed in staff lounges.
- A daily abuse incident reporting audit was started and will be conducted by the DON or appointed designee daily to verify timeliness of incident reporting, proper resident protection procedures, and staff compliance with facility policy.