Failure to Immediately Report and Respond to Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure when a Dining Associate (DA) witnessed a Certified Nursing Aide (CNA) allegedly physically abusing a cognitively impaired resident during a meal. The DA observed the resident expressing that the soup was too hot and attempting to resist, while the CNA pushed the resident's hands down, grabbed their arm, and manipulated it to make a gripping motion. Despite witnessing this, the DA did not immediately report the incident, waiting three days before notifying administration, during which time the CNA continued to work and had access to the resident and others. The resident involved had significant medical conditions, including Alzheimer's disease, chronic kidney disease, and diabetes, and was assessed as having severely impaired cognitive skills with total dependence on staff for eating. The care plan for the resident did not include information that the resident would say food was too hot to indicate fullness, which was relevant to the incident. The CNA stated that the resident often said food was hot as a way to communicate being done with eating, and that she would hold the resident's hand to comfort them during meals. The facility's policies required immediate reporting of suspected abuse and removal of implicated staff from resident care pending investigation. However, the delay in reporting by the DA and the continued assignment of the CNA to resident care for three shifts after the alleged incident meant that the facility did not protect the resident or others from potential abuse as required. This failure resulted in an Immediate Jeopardy situation, as the CNA was not suspended until the allegation was finally reported.
Removal Plan
- Resident #1 received a body and pain assessment after DA #1 reported the allegation of abuse, with no injuries or pain noted; and emotional support and reassurance were provided.
- CNA #1 was suspended and educated on the facility's abuse policy before their next scheduled shift.
- DA #1 and CNA #1 were educated on the facility's abuse policy.
- The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Licensed Nursing Home Administrator (ALNHA), Assistant Director of Nursing (ADON), or designee conducted education with all current staff in all departments on the facility's abuse prevention policy to include immediately reporting all allegations of abuse.
- The LNHA or designee reviewed the last thirty days of grievances/concerns to identify abuse concerns.
- The Social Worker (SW) interviewed residents with Brief Interview for Mental Status (BIMS) scores of 8 or above (moderately impaired to intact cognition) to identify abuse, neglect or care related concerns.
- A licensed nurse completed a physical assessment/observation of all residents with BIMS scores of 7 or below (severe cognitive impairment).