Failure to Protect Residents During Abuse and Neglect Investigations
Penalty
Summary
Facility staff failed to take immediate protective measures following allegations of abuse and neglect involving two residents. In the first instance, a resident reported to the facility administrator that a housekeeper threatened to beat him up. Although the administrator documented the incident and reported it to the state regulatory agency, the alleged perpetrator was allowed to work the remainder of the shift, as confirmed by timecard records. This action provided the employee continued access to other residents during the ongoing investigation. In the second case, a cognitively intact resident reported neglect and intimidation by a CNA, including delayed incontinence care and aggressive behavior, which led the resident to contact the police. Despite the substantiated allegation of neglect, the CNA was permitted to work a full shift the following day, providing direct care to other residents. Facility policies reviewed did not address the need to protect residents from alleged perpetrators during investigations, and supervisory staff did not take measures to restrict the accused staff members' access to residents during the investigation period.