Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse policy and procedures in the areas of prevention, protection, reporting, and investigation following an incident in which a nurse aide witnessed another staff member physically abuse a resident with dementia during incontinence care. The incident involved the staff member grabbing both of the resident's wrists and slapping the resident's hand after the resident resisted care. The witnessing nurse aide did not immediately intervene or report the abuse, instead waiting until the end of her shift to inform the nurse on duty. As a result, the accused staff member continued to provide care and remained on the floor for the remainder of her shift. Upon being informed of the incident at shift change, the nurse and another nurse present did not immediately notify administration or take steps to protect the resident or other residents from further potential abuse. The nurse checked on the resident but did not observe any marks and decided, along with the oncoming nurse, to report the incident to management the following morning. The delay in reporting meant that the accused staff member was not suspended or removed from resident care until after the next shift, contrary to facility policy which required immediate reporting and protection of residents. The facility's investigation into the abuse allegation was incomplete, as it did not include interviews or assessments of other residents who may have received care from the accused staff member during the remainder of her shift. The investigation focused only on the direct witnesses and the accused, and did not determine whether other residents were affected. The facility's own policy required immediate reporting, collection of statements from all witnesses, and assessment of all potentially affected residents, but these steps were not followed.