Failure to Investigate and Prevent Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents, all of whom were reviewed for abuse. In one case, a cognitively intact resident reported that a CNA touched her anus during pericare and made her feel uncomfortable through unwanted physical contact and inappropriate language. The incident was reported to the Social Services Director, who informed the Administrator. The CNA was initially placed on leave, and an abuse questionnaire was conducted with other residents, but the investigation concluded the allegation was unsubstantiated, and the CNA was allowed to return to work with the condition of no further contact with the reporting resident. Another resident with moderate cognitive impairment reported that the same CNA attempted to sexually abuse her and her roommate. She described the CNA entering her room at night, attempting to touch her, and then moving to her roommate, where she witnessed inappropriate contact and heard inappropriate comments. Nursing notes documented these allegations, and a police report was filed. The roommate, who also had moderate cognitive impairment and a history of adult sexual abuse, was found fearful and confused, unable to recall the events or the CNA involved. Her husband was informed of an assault but was not given details. A fourth resident, cognitively intact, reported that the CNA made inappropriate comments and attempted to groom her, though she denied any inappropriate physical contact. She did not report these incidents to staff at the time. The Administrator stated that after the initial allegation, the CNA was suspended pending investigation, but the investigation relied on resident questionnaires and was deemed unsubstantiated, allowing the CNA to return to work. Only after further allegations did the facility bar the CNA from returning. The facility's investigation process did not thoroughly address or substantiate the multiple allegations, and steps to prevent further abuse were not adequately implemented.
Removal Plan
- Facility sent in late reportable for the second and third identified residents.
- Change in Condition with provider and responsible parties notified.
- Whole house abuse questionnaire completed with residents.
- Skin check for residents involved as appropriate.
- Psychiatric service referral for residents involved as appropriate.
- CNA in question was terminated.
- Center leadership staff will be re-educated on the following areas by Market Resource Nurse.
- Investigations start with removal of staff member and protection of resident.
- Abuse questionnaires to be completed by those who have the potential to be affected by the staff member or resident.
- Individual self-reports to follow for any other residents who are identified during the questionnaires.
- Change in condition with provider and responsible party notification for those affected or impacted.
- Skin checks for residents involved as appropriate Social services to complete wellness checks and offer psychosocial support as appropriate.
- Psychiatric services referral for residents involved as appropriate.