Failure to Investigate and Address Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and respond to multiple allegations of abuse and neglect involving four residents. One resident reported that a CNA used inappropriate language during care and requested not to be cared for by that CNA in the future. During the investigation, another staff member reported that the same CNA made an inappropriate comment to a second resident. Both residents had moderately impaired cognition and activated Powers of Attorney for Healthcare. The investigation did not document that staff education was provided to prevent further verbal abuse, as required by facility policy. Additionally, grievances from two other residents alleged that a different CNA neglected their care by asking them to perform tasks they were unable to complete and leaving them without assistance. One resident described being left on the toilet without a call light within reach and hearing inappropriate language from staff. Despite these grievances, the only documented staff education occurred a month prior to the incidents, and there was no evidence of further education or competency checks following the allegations. Interviews with staff confirmed that abuse/neglect education had last been provided several months before the incidents.