F0607

E

Failure to Implement Abuse Policy After Alleged Verbal and Emotional Abuse by CNA

Santee, California Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its written abuse policy regarding identification, reporting, investigation, and prevention of abuse. A cognitively intact resident with quadriplegia, admitted after a motor vehicle accident, reported an incident in which a CNA allegedly acted in a verbally aggressive and threatening manner when she requested food from the refrigerator. The resident stated the CNA demanded that she say hello to him before he would help her, repeated this in an angry tone, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident reported that the CNA then charged toward her with his chest out and aggressive arm movements, in a way that appeared as if he wanted to physically fight her. She stated she was scared because her electric wheelchair moved slowly and she was worried she could not get away from him fast enough. Another resident present confirmed witnessing the incident as described.

Following the incident, the resident reported the event to another CNA and a charge nurse, telling them she was scared and did not feel safe with the CNA involved. Progress notes documented that the resident appeared to be in emotional distress on the night of the incident and continued to verbalize disbelief and upset about the incident over the next several days. Notes further showed that she stayed in bed, refused to get out of bed, declined to talk to staff about the incident, and avoided social interaction. The resident later told the social worker she did not feel safe with the CNA being around her and expressed concern that the CNA could lose his temper with her or other residents. A psychotherapy note documented that the resident reported feeling unsafe and frozen during the interaction, spending three consecutive days in bed, and avoiding social interaction to prevent retraumatization.

Despite these reports and observations, the facility did not identify, report, or investigate the allegation of abuse in a timely and thorough manner as required by its abuse policy. The SOC 341 abuse report was not completed and faxed to the state agency until days after the incident, and the administrator, who served as the abuse coordinator, stated she did not consider the incident to be abuse and did not interview the resident. The administrator reported that she only interviewed the CNA and relied on information from nursing supervisors, who did not relay the resident’s full account or her expressed fear and emotional distress. Staff interviews revealed that the charge nurse and other staff recognized the incident as verbal or emotional abuse and believed it should have been reported immediately, but this did not occur. Additionally, staffing records showed that the CNA continued to be assigned to provide resident care on two subsequent days after the allegation, and there was no documented assessment of risk to other residents during the investigation period, despite the facility’s policy allowing reassignment of accused staff when there is risk to residents.

The facility’s abuse policy required immediate reporting of abuse allegations to law enforcement and regulatory agencies within specified time frames, completion of the SOC 341 by the employee who heard about the abuse, and implementation of effective measures to ensure that further potential abuse did not occur while an investigation was in process. The policy also required internal reporting to the administrator and allowed for moving an accused employee to another assignment if there was risk to residents, and it directed that staff be educated to identify behaviors such as increased fearfulness as potential indicators of abuse. In this case, the facility did not follow these procedures: the administrator was not fully informed of the resident’s statements and emotional condition, the resident’s increased fearfulness and withdrawal were not identified or treated as potential signs of abuse under the policy, and the CNA remained in resident care assignments without documented risk assessment. As a result, the facility failed to implement its abuse policy in the areas of timely reporting, thorough investigation, risk assessment for other residents, and recognition of behavioral indicators of possible abuse.