Failure to Timely Report, Protect, and Investigate Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting, protection, and thorough investigation of alleged staff-to-resident abuse and misappropriation of medications. In one instance, a certified nurse aide (CNA) was accused by a resident of making the resident feel threatened, resulting in the resident staying awake all night out of fear. Despite the complaint being brought to the attention of the Administrator, the CNA continued to work with residents before being suspended, and the investigation lacked statements from all potential witnesses. The facility's policy required immediate investigation and protection of residents, but these steps were not fully implemented. Another incident involved a resident with multiple chronic conditions, including respiratory failure and cognitive communication deficit, who reported that a CNA smacked her hand during care. The resident reported the incident to a registered nurse (RN), who relayed it to the former Director of Nursing (DON). The investigation was incomplete, as it did not include interviews with other residents, ongoing monitoring, or staff education. The CNA was not suspended during the investigation, and there was no documentation of disciplinary action. Additionally, the facility failed to properly investigate a case of missing narcotic medication. Thirty Norco tablets were reported missing from a medication cart, and a drug test was allegedly administered to the last nurse with access. However, there was no evidence that the drug test was actually completed, and it was later determined that the drug test form had been forged by a former human resources staff member. The facility's employee handbook required drug testing under reasonable suspicion, but this process was not followed.