Failure to Investigate and Respond to Abuse Allegation
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and respond to an allegation of abuse involving a resident with hemiplegia, hemiparesis, major depressive disorder, nicotine dependence, and a contracture to the left hand. The resident, who had intact cognition and was responsible for their own healthcare decisions, reported that a CNA entered their room, yelled, swore, and instructed the resident to urinate in their brief instead of providing assistance to the bathroom. The incident was witnessed by another CNA, who did not immediately report the event but instead waited until later in the day to notify a nurse. The facility's policy required immediate removal of the alleged perpetrator and prompt reporting, but staff did not intervene at the time of the incident or ensure the resident's immediate protection. The investigation into the incident was incomplete. Although the facility suspended the accused CNA and contacted law enforcement, the documentation of staff education on abuse prevention and reporting was lacking. Several staff members, including those directly involved or present during the incident, did not have signed confirmation that they received or understood the required education. Additionally, the facility did not provide evidence of comprehensive, all-staff education following the incident, despite ongoing concerns about staff telling residents to urinate in their briefs and not responding to call lights in a timely manner. The facility's call light logs showed significant delays in response to the resident's requests for assistance, with call lights remaining on for extended periods. Interviews with staff revealed that the resident's needs were not promptly addressed, and there were multiple reports of similar issues occurring beyond the initial incident. The lack of immediate intervention, delayed reporting, and insufficient documentation of staff education contributed to the facility's failure to ensure a safe environment free from abuse and neglect, as required by policy and regulation.