Failure to Train Contracted and Agency Staff on Abuse, Neglect, and Reporting Requirements
Penalty
Summary
The facility failed to provide required training to all staff, including contracted and agency personnel, on dementia care and on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and resident abuse prevention. The facility’s Abuse policy, revised April 2025, states that it applies to all staff, including employees, consultants, contractors, volunteers, students, and other caregivers, and requires that care and services be delivered in a way that promotes residents’ rights to be free from abuse, neglect, misappropriation, exploitation, or privacy violations. Despite this policy, the regional nurse consultant was unable to produce documentation of facility-specific abuse training for contracted or agency staff and stated that these staff were educated on abuse only by their agencies prior to working at the facility. Record review showed an allegation of neglect initiated by a hospice CNA, who believed a resident receiving care from him and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period. The incident report documented that the hospice CNA observed suspected neglect on 11/9/25 but did not report it to the facility until 11/19/25, a delay of ten days. The facility’s investigation concluded that the contracted hospice CNA failed to report suspected neglect in a timely manner. In interviews, an agency CNA confirmed she had not received any supplementary training from the facility on facility policies or expectations related to abuse and neglect, and the regional nurse consultant and DON acknowledged that the facility had not provided abuse-reporting training to agency staff and needed better coordination with the hospice agency regarding communication of concerns.
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