Failure to Prevent and Intervene in Staff-to-Resident Abuse
Penalty
Summary
The facility failed to properly intervene and prevent a Certified Nurse's Aide (CNA) from engaging in inappropriate and abusive interactions with multiple residents over several occasions. Multiple residents reported incidents involving the CNA, including inappropriate touching during peri care, unwanted hugging, and the use of inappropriate language. One resident, who was cognitively intact and had a history of stroke and paralysis, reported that the CNA touched her anus during peri care and made her feel uncomfortable. She also described repeated unwanted physical contact and inappropriate comments from the CNA. Despite these reports, the CNA was initially allowed to return to work with the restriction of not caring for the reporting resident, rather than being fully removed from resident care pending investigation. Another resident, also cognitively intact, reported that the same CNA attempted to touch her body during the night shift and, after being rebuffed, proceeded to touch her roommate under the blanket while making inappropriate comments. The roommate, who had moderate cognitive impairment and a diagnosis of Wernicke's encephalopathy, was later found fearful, confused, and agitated, and was evaluated by a Sexual Assault Nurse Examiner. The roommate was unable to recall the events during subsequent interviews, but her husband reported a significant decline in her mental and physical condition following the incident. A third resident described the CNA making inappropriate and suggestive comments during care, which made her uncomfortable, though she did not report any physical abuse. The facility's initial response to the allegations was to conduct resident questionnaires, which did not reveal further abuse at that time. The Administrator did not substantiate the initial allegation and allowed the CNA to return to work, only restricting contact with the reporting resident. It was only after additional allegations surfaced that the CNA was removed from the facility. The facility's failure to immediately and thoroughly intervene allowed the CNA continued access to residents, resulting in further incidents of alleged abuse.
Removal Plan
- Reportable sent for the initial resident.
- Two extra reportable were sent in late after new allegations of abuse.
- CNA in question was terminated.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- Whole house abuse questionnaire completed with residents.
- Center Nursing staff will be re-educated on the following areas by the Nurse Educator/Designee: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately.
- The aggressor should be placed on 1:1 supervision immediately and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others.
- Documentation needs to occur to reflect this monitoring and clear discontinuation of the 1:1 and reasoning by a provider.
- If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed and they have been cleared by the Administrator or DON to return.
- The provider, nurse manager and family have to be notified immediately.
- The eInteract change in condition assessment needs to be completed filled out with all the details of what happened.
- Monitoring and interventions need to continue to happen and be documented if the residents remain in the building, until we know they have stabilized per the provider or have left the center.
- Administrator and DON were educated on the need for individual reports for each resident regarding abuse.
- Center has implemented a new abuse questionnaire that allows for a more thorough investigation.
- When an allegation of abuse is identified, the center will report to the state agency.