Failure to Investigate and Prevent Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and did not take adequate steps to prevent further abuse involving four residents. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that a CNA touched her anus during pericare and later attempted to hug her and used inappropriate language. The incident was reported, and the CNA was initially placed on leave, but the investigation relied primarily on abuse questionnaires with other residents and did not substantiate the allegation, allowing the CNA to return to work with the condition of no further contact with the reporting resident. Another resident, with moderate cognitive impairment and a history of heart failure, reported that the same CNA attempted to sexually abuse her and her roommate. She described the CNA entering her room at night, attempting to touch her, and then moving to her roommate, where inappropriate physical contact and comments were observed. The roommate, who also had moderate cognitive impairment and a diagnosis of Wernicke's encephalopathy, was found fearful and confused, and a SANE nurse was called to evaluate her for sexual assault. The roommate's husband was informed of an assault but not given details, and he noted his wife's increasing confusion. A fourth resident, cognitively intact, reported that the CNA made inappropriate comments and attempted to groom her, though she denied any physical abuse and had not reported these incidents previously. The facility's investigation into these allegations was limited, with the administrator and social services director disagreeing on whether the abuse occurred. The administrator did not substantiate the allegations and allowed the CNA to return to work until further allegations led to the CNA's termination. Documentation and interviews revealed that the facility did not conduct a thorough investigation or implement sufficient measures to prevent further abuse after the initial reports.
Removal Plan
- Facility sent in late reportable for the second and third identified residents.
- Change in Condition with provider and responsible parties notified.
- Whole house abuse questionnaire completed with residents.
- Skin check for residents involved as appropriate.
- Psychiatric service referral for residents involved as appropriate.
- CNA in question was terminated.
- Center leadership staff will be re-educated on the following areas by Market Resource Nurse.
- Investigations start with removal of staff member and protection of resident.
- Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident.
- Individual self-reports to follow for any other residents who are identified during the questionnaires.
- Change in condition with provider and responsible party notification for those affected or impacted.
- Skin checks for residents involved as appropriate.
- Social services to complete wellness checks and offer psychosocial support as appropriate.
- Psychiatric services referral for residents involved as appropriate.