Failure to Identify and Track Suspected Perpetrators in Abuse Investigations
Penalty
Summary
The facility failed to ensure that Self-Reported Incident (SRI) investigations were complete, specifically by not identifying suspected perpetrators (SP) in the SRI tracking section, despite being aware of the staff member involved. In two separate incidents involving two residents, a Certified Nursing Assistant (CNA) was named in the investigations for yelling at and raising her arm toward residents, one of whom had dementia and only spoke Spanish. The CNA was reported by other staff for aggressive behavior, including yelling at residents and demanding they speak English. Despite these reports and the CNA being named in multiple SRIs, the facility did not list her as an SP in the required tracking sections, even after being notified by the State agency to do so. Further review revealed that the same CNA was involved in several other SRIs, yet the facility continued to omit her from the SP tracking section. The facility's policy required accurate and timely reporting of all incidents and identification of those involved, but this was not followed. Interviews with staff confirmed the CNA's behavior and the lack of appropriate action or documentation by the facility. The deficiency affected two residents directly and had the potential to affect all residents on the secure unit.