Failure to Protect Residents and Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse were thoroughly investigated and that immediate steps were taken to protect residents from further abuse. On 9/27/25, the facility became aware of an abuse allegation involving a resident with diagnoses including Type 2 Diabetes and depression, who was cognitively intact. The incident involved a verbal altercation between the resident and a certified nursing assistant (CNA), during which both parties were observed yelling at each other, and the CNA was accused of antagonizing the resident. Despite the facility's policy requiring immediate suspension of implicated staff pending investigation, the CNA continued to provide direct care to residents after the incident occurred. Interviews and record reviews revealed that the facility did not provide evidence of protection for the resident involved or for other residents in the facility following the allegation. The CNA was not immediately removed from resident care areas and continued working the shift, although did not provide care to the specific resident involved. Nursing staff expressed discomfort with the CNA's continued presence, noting that the CNA would look into the resident's room and give looks, which contributed to an unsafe environment. The incident was not reported to the DON or NHA until days later, and the state agency was notified several hours after the event. Additionally, the facility did not provide abuse prevention education to all staff following the incident, as required by policy. Only one LPN received education on reporting allegations of abuse and the facility's abuse prevention policy, while other staff, including those directly involved, did not receive such education. The facility's failure to follow its own policies and federal guidelines regarding immediate protection, investigation, and staff education contributed to the deficiency.