Failure to Report and Act on Allegations of Rough Care and Derogatory Comments
Penalty
Summary
The deficiency involves multiple staff members failing to report allegations of rough care, bruising, neck pain, and derogatory comments to the Administrator/Abuse Prevention Coordinator as required by facility policy, resulting in delayed investigation and failure to remove the alleged staff perpetrators from resident care. One resident, who had moderate cognitive impairment, limited range of motion in both upper extremities, and was dependent for most ADLs, reported that a CNA with a ponytail was rough during transfers and care, causing bruises on both forearms and neck pain that made her cough and feel choked. During an interview, the resident showed bruises on both posterior mid-forearms, described as purple with yellow halo-like fading, and stated she was scared the CNA might hurt her again. The resident reported that she had told the Social Service Director about the rough care and bruising, and that the Social Service Director had noticed the bruises and said she would report the matter to her supervisor, but no one subsequently came to interview the resident about the allegation. The facility’s concern log documented a grievance from this resident indicating she was tired of a mean CNA on night shift who was rough with care, and this concern was assigned to the Administrator. The Social Service Director later confirmed that she had received and recorded this grievance, including the resident’s report that the CNA was rough with care, caused bruising to both forearms, and caused neck pain, and stated she reported the allegation to the Interim Administrator/Abuse Prevention Coordinator. However, the Interim Administrator/Abuse Prevention Coordinator, the DON, and the Regional Nurse Consultant all stated they had no reported allegations of abuse regarding this resident. The CNA identified by the resident continued to work a full shift after the grievance was documented and was not suspended until days later, after the surveyor reported the allegation to facility leadership. A second resident, cognitively intact and receiving care following joint replacement surgery, reported to the Social Service Director that a CNA had been rough with care while on the phone during care, was rude, and did not pay attention to what she was doing. The resident described the CNA’s physical characteristics, stated that the CNA was talking to someone else instead of engaging with him, and reported that she was rough and rushed. The Social Service Director confirmed that the resident reported the CNA was rough with care and on the phone, and that she personally called the CNA, who is her relative, on her own cell phone outside the building and yelled at her about being on the phone during care. The Social Service Director stated she did not view the rough care as abuse because she knew the CNA and believed she was a good person, and therefore did not report the allegation as abuse to the Administrator, despite acknowledging knowledge of the requirement to report abuse immediately. The same resident later told the surveyor that the CNA had belittled him during care by telling someone on the phone that he was lazy and did not need all the help she had to give him, and that he reported this to the Social Service Director, an LPN, and a physical therapy assistant. The LPN confirmed that the resident reported that the CNA was rough with care, called him lazy, and said he could not do anything for himself, and stated she reported the issue to the DON but did not know who the Administrator was. The DON and Interim Administrator/Abuse Prevention Coordinator both stated they were not aware of this resident’s grievance or allegation of rough care. Timecard records showed that the CNA identified in this second allegation continued to work multiple shifts on various halls with full access to residents after the allegation was made and before she was suspended, and there was no investigation documented at the time of the survey. The facility’s Abuse, Neglect, Exploitation policy required immediate protection of residents and immediate reporting of alleged violations to the Administrator and appropriate agencies, but these procedures were not followed in these instances.
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