Failure to Implement Abuse Policy and Pre-Employment Screening
Penalty
Summary
Facility staff failed to implement their abuse and neglect prevention policy for a certified nursing assistant (CNA) who neglected a cognitively intact resident. The resident reported that staff did not respond to call lights for incontinence care, resulting in the resident remaining in feces for hours. The resident felt threatened by the CNA's aggressive behavior and called the police. Text messages sent to the DON and the resident's child documented the incident, and the facility's own investigation substantiated the allegation of neglect. The charge nurse was aware of the CNA's lack of response to resident needs, and the CNA was found sleeping during the shift, requiring a nurse to wake her to provide care. Further review revealed that the facility failed to verify the CNA's active certification and did not obtain a criminal background check prior to employment. The CNA had previously worked at the facility, but upon rehire, the required checks were not repeated, contrary to facility policy. The human resources director confirmed that neither a current background check nor license verification was present in the personnel file at the time of the incident. The facility's policy required criminal background and reference checks for all employees, but these procedures were not followed for this CNA.