Failure to Screen and Exclude CNA with Prior Abuse Finding Leading to Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by hiring and continuing to employ a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on the OIG/medical exclusion and State Board lists. The CNA’s background screening report, completed prior to hire, clearly indicated a finding of patient abuse, yet the facility proceeded with employment. The facility also failed to obtain and document reference checks from previous and/or current employers or make reasonable efforts to uncover information about any past criminal prosecutions for this CNA, despite policy requirements to screen potential employees for a history of abuse, neglect, or mistreatment. The Administrator later stated he was not aware of the CNA’s abuse finding and that the facility does not hire nursing staff with such findings. The deficiency was further evidenced by an incident involving a resident with paraplegia and intact cognition, as shown by a BIMS score of 15 and clear communication abilities. According to an SBAR progress note, the resident reported that the CNA verbally and physically abused him, and the resident appeared anxious, intimidated, and uncomfortable with care. In an interview, the resident stated he had asked the CNA for help with clothing and water, and the CNA told him to stand up and help himself, then spilled water on the resident’s wheelchair and damaged items in his wallet, leaving the resident upset and anxious. In a separate interview, the CNA described an event in which a bottle of hot sauce and water slid from a bedside table and broke while the CNA was moving the table. These events, combined with the documented abuse finding on the CNA’s background screening and the lack of reference checks, demonstrate the facility’s failure to implement its abuse prevention policy not to employ or continue to employ anyone found guilty of abuse.
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