Failure to Prevent and Respond to Staff Abuse Allegations
Penalty
Summary
The facility failed to protect residents from abuse by not properly intervening and preventing a Certified Nurse's Aide (CNA) from engaging in inappropriate and abusive interactions with multiple residents over several occasions. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that the CNA touched her anus during peri care and made her feel uncomfortable. She also described the CNA attempting to hug her and using inappropriate language. The incident was reported to the Social Services Director, who informed the Administrator and the facility's Abuse Officer. Despite the report, the CNA was allowed to return to work the same day with the only restriction being no further contact with the reporting resident. Another resident, also cognitively intact and with multiple medical diagnoses, reported that the same CNA attempted to sexually abuse her during the night shift. She described kicking the CNA away and verbally confronting him, after which the CNA moved to her roommate and was observed placing his hand under the roommate's blanket and making inappropriate comments. The roommate, who had moderate cognitive impairment and a history of Wernicke's encephalopathy, was later found on the floor, confused and fearful, and was evaluated by a Sexual Assault Nurse Examiner. The roommate's husband reported that his wife was emotionally distressed and experienced a decline in her condition following the incident. A third resident reported that the CNA made inappropriate comments to her during personal care, which she found unsettling and suggestive of grooming behavior, though she denied any physical abuse. She did not report these incidents initially due to the CNA's night shift schedule and limited contact. The facility Administrator, upon being informed of the initial allegation, conducted an investigation but did not substantiate the abuse and allowed the CNA to return to work. It was only after additional allegations surfaced that the CNA was removed from the facility. The facility's initial response did not include immediate removal of the accused staff member or comprehensive investigation, resulting in continued risk to other residents.
Removal Plan
- Reportable sent for the initial resident.
- Two extra reportable were sent in after new allegations of abuse.
- CNA in question was terminated.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- Whole house abuse questionnaire completed with residents.
- Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately.
- The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others.
- Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center.
- Administrator and DON were educated on the need for individual reports for each resident regarding abuse.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- When an allegation of abuse is identified, the center will report to the state agency.