Failure to Immediately Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure to protect all residents from abuse when a severely cognitively impaired resident alleged physical abuse by a CNA. After the incident, the CNA was removed from the resident's assignment but remained on the same nursing unit, continuing to assist other residents and having access to the alleged victim. This action did not ensure the immediate protection of the resident or others, as required by the facility's policy. The incident occurred when the resident, who had a history of severe cognitive impairment and multiple medical diagnoses including vascular dementia and muscle wasting, activated their call light. The CNA responded, and shortly after, the LPN heard the resident screaming. Upon entering the room, the LPN observed water on the floor and the resident alleging that the CNA had pulled their hair and beaten them. The LPN reported the incident to the Nursing Supervisor, who changed the CNA's assignment but did not remove the CNA from the unit. The CNA continued to work on the unit until the end of the shift, during which time the resident was observed following the CNA around, repeatedly stating that the CNA had beaten them. Interviews with facility leadership confirmed that staff involved in abuse allegations should be immediately separated from residents and sent home pending investigation. However, in this case, the CNA was not sent home until the end of the shift, several hours after the allegation was made. Documentation and interviews revealed inconsistencies in staff accounts of the incident and the timing of notifications to facility leadership. The failure to immediately remove the CNA from the unit after the allegation was made resulted in continued access to the resident and other residents, contrary to facility policy and regulatory requirements.
Removal Plan
- CNA #1 was suspended pending an investigation and received in-servicing on abuse upon her return to the facility.
- The local police, physician, and family were notified.
- Resident #1 received a skin assessment and neurological checks, a psychological and social services consultations, and their care plan was updated.
- LPN #1 and the Nursing Supervisor were verbally educated on abuse procedures.
- The Director of Nursing provided LPN #1 and the Nursing Supervisor with abuse training including: different forms, prohibiting, identifying, recognizing, compliance with reporting, prevention, and immediate response.
- The Regional Director of Nursing in-serviced the Director of Nursing and Licensed Nursing Home Administrator on abuse.
- The Director of Nursing began educating all staff on abuse.
- All supervisors and managers were educated to send employees home immediately upon allegations of abuse or neglect.