Failure to Train Staff on Abuse Reporting Requirements
Penalty
Summary
The facility failed to ensure that staff were adequately trained regarding the reporting requirements for alleged resident abuse, as outlined in its Abuse and Neglect Prohibition Policy. A review of a resident's records revealed that after an incident involving verbal aggression between a resident and a Certified Nurse Assistant (CNA), the event was documented in the progress notes but was not reported to the Administrator or to the appropriate licensing and certification authorities. Interviews with staff indicated a lack of awareness about the proper procedures and timelines for reporting alleged abuse, particularly among night shift staff. One Licensed Vocational Nurse (LVN) stated he had not received abuse prevention training in a long time and was unsure of the reporting process. The resident involved had a history of aggressive behavior related to bipolar disorder and legal blindness, and was able to understand and communicate with others. The care plan for this resident included interventions for managing aggressive behavior, but during the incident, both the resident and the CNA exchanged inappropriate language. The facility's policy required ongoing training for all employees on abuse prevention and reporting, but the Administrator could not recall when the last training was conducted, and acknowledged that not training all staff, including night shift, could result in failures to report and investigate alleged abuse in a timely manner.