Failure to Implement Abuse Policy and Protect Staff from Retaliation
Penalty
Summary
The facility failed to implement its abuse prevention policy in response to an allegation of staff-to-resident physical abuse, specifically failing to immediately suspend the accused staff member from resident contact pending investigation. A resident was found with a swollen and painful left arm, later diagnosed as a closed supracondylar fracture of the left humerus. There was no documentation or evidence of a fall or other accidental cause for the injury in the resident's records. Multiple staff interviews indicated that the resident and another resident reported that a staff member had been rough or abusive during care, with statements describing the staff member as having snatched and hit the resident's arm against the bed rail. Despite these reports, the accused staff member was not immediately suspended and was reassigned to a different unit rather than removed from resident contact. The investigation process was further compromised by inconsistent and fabricated documentation. The Director of Nursing (DON) and Administrator attempted to attribute the injury to an unreported fall, despite the lack of any supporting documentation or witness statements, except for the statement from the accused staff member. Other staff, including CNAs and an LPN, consistently denied that a fall had occurred and expressed concerns that the injury was a result of physical abuse. The DON was observed fabricating a witness statement to support the fall narrative, and no evidence was provided to substantiate that a fall had taken place. Additionally, the facility failed to protect staff from retaliation after reporting suspected abuse. An LPN who reported concerns about abuse was terminated during the investigation, with the termination attributed to failure to report a fall that was not documented or corroborated by any evidence. The facility's own abuse policy prohibits retaliation against employees who report suspected abuse, but this policy was not followed. The Regional Supervisor confirmed that the environment created by such retaliation could discourage staff from reporting abuse, potentially affecting all residents.