Failure to Immediately Remove Abusive and Intoxicated Staff Member
Penalty
Summary
The facility failed to immediately implement effective measures to prevent further potential abuse, neglect, or mistreatment of residents after staff members observed another staff member verbally and physically abusing residents. According to facility policy, any employee suspected of abuse is to be immediately removed from duty pending investigation. However, after multiple staff observed a CNA (Staff A) appearing intoxicated, acting erratically, and being verbally and physically abusive to residents, she was not removed from the unit until near the end of her scheduled shift. Two residents were directly affected by these actions. One resident, with severe cognitive impairment and a history of schizophrenia and bipolar disorder, was observed being handled roughly during ADL care, including being pushed on their side and verbally insulted about their weight. The resident was heard yelling in pain during care. Another resident, with intact cognition and a history of stroke and anxiety, was verbally abused and refused care by the same CNA, who used derogatory language and refused to assist when asked. Despite multiple staff, including a CNA, LPN, and RN, witnessing and reporting Staff A's behavior—such as confusion, intoxication, aggression, and inappropriate comments—Staff A was not immediately removed from the premises. She remained in the facility for over an hour after being told to leave and was only escorted out after the end of her shift. The DON acknowledged that, although staff identified the abuse and intoxication, Staff A was not told to leave immediately, contrary to facility policy.