Failure to Prevent Suspended LVN from Facility Access After Alleged Abuse
Penalty
Summary
The facility failed to prevent further potential abuse after an alleged incident of physical abuse involving a resident with severe intellectual disability, anxiety disorder, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficit. The resident, who had a BIMS score indicating severe cognitive impairment, was reportedly grabbed by the shirt and neck by an LVN, causing the resident to choke. This incident was witnessed by two CNAs, who later confirmed the details in a voice recording and interviews. The resident expressed fear and distress during an interview, stating that the LVN had choked him. Despite the LVN being suspended pending investigation on the morning following the incident, the LVN returned to the facility that same night to document an incident report. Staff on duty were unaware of the suspension and allowed the LVN access to the facility, including the computer and secured unit, although they did not observe direct interaction with residents. The CNAs stated that if they had known about the suspension, they would have reported the LVN's presence and not allowed access, recognizing the risk posed to residents and staff. The facility's policies required that suspended employees not be permitted on the premises or to engage with residents or staff during suspension. However, the administrator acknowledged that there was no process in place to inform staff of suspensions, relying instead on the suspended employee's understanding of the policy. This lack of communication allowed the suspended LVN to return to the facility, placing residents and staff at risk and resulting in the identification of an Immediate Jeopardy situation by surveyors.