Failure to Immediately Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately and thoroughly investigate an allegation of staff-to-resident abuse and to ensure resident protection during the investigation. The facility’s Abuse and Neglect Policy requires the Administrator, DON, or designee to begin an internal investigation immediately and report to DHSS when an allegation arises. A resident with multiple sclerosis and minimal cognitive impairment, admitted in early February, reported to a CNA that a CNA staff member had been rough during incontinence care, turned on a bright light while the resident was sleeping, and then punched the wall three times above the resident’s head after being told to stop. The resident stated fear of this CNA and requested that the CNA not return to the room. CNA A documented the allegation in a written statement and immediately reported it to RN C during the night shift. CNA A then attempted to contact the DON and the Administrator by phone and text, sending a picture of the written statement to both, but received no response at that time because both leaders were asleep and did not hear their phones. RN C reassigned the resident’s care to CNA A and instructed CNA B not to return to the resident’s room, but did not enter the resident’s room or interview the resident about the allegation. RN C stated that being rough with cares was not considered an allegation of abuse and therefore did not report the incident to the DON or Administrator during the night. The Administrator and DON later acknowledged that rough care and punching a wall constituted abuse and that an investigation should have been started immediately. Other nursing staff interviewed indicated that any report of rough care where a resident does not feel safe should be treated as an abuse allegation, with immediate steps to ensure safety and report to leadership. Despite this, there was a delay from the time of the initial report during the night until the Administrator became aware and began an investigation later that morning, during which time the staff member implicated in the allegation continued to work independently with residents.
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