Failure to Immediately Report and Act on Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of physical abuse involving a resident with severe cognitive impairment who was dependent on staff for care. The resident, admitted in December 2025 with dementia and generalized muscle weakness, had an MDS assessment indicating severe cognitive impairment and total dependence on staff. The facility’s abuse policy, revised March 2023, required that when abuse is observed, reported, or suspected, residents must be immediately protected from the alleged abuse and the employee immediately suspended pending investigation. On 12/13/25, a nurse heard the resident’s family member yelling and swearing at a CNA, accusing him of abusing the resident and causing bruises on the resident’s arms. The nurse stated she removed herself from the situation because of the yelling and did nothing further, and there was no documentation that she notified a supervisor or administrative staff of the altercation or the abuse allegation. On the same date, the nursing supervisor reported that the family member only complained that the CNA had not properly cleaned the resident and did not mention abuse. The next day, the family member told the nursing supervisor she wanted to talk to the CNA because she believed he was responsible for bruises on the resident’s arms. The nursing supervisor did not immediately report this allegation to administration, and there was no documentation that she initiated an investigation or had the CNA removed from the schedule at that time. The DON later stated that any time an allegation of abuse is made against a staff member, the staff member must be suspended immediately to protect the resident and other residents, and acknowledged that the nursing supervisor should have reported the allegation immediately. The administrator reported first learning of the allegation on 12/15/25, at which time the CNA was not working, and he then obtained a statement and suspended the CNA. As a result of the nurse’s and nursing supervisor’s inaction, the CNA continued to work and interact with residents, and there was a two-day delay in the facility initiating an investigation into the abuse allegation.
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