Failure to Timely Investigate Abuse Allegation and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of staff physical abuse and to immediately protect residents after the allegation was made. Facility policy required that the DON immediately initiate an abuse incident report, begin an investigation, and prevent further potential abuse, including reassigning or suspending the involved employee. However, after an evening incident in which a CNA reported being hit by a resident and the resident alleged the CNA had punched them, the investigation was not initiated until the following day, and there was no immediate documentation of protective measures for residents. Resident #1, who had severe cognitive impairment, hemiplegia, diabetes, high blood pressure, and was dependent on staff for all ADLs, allegedly told staff that a CNA punched them in the stomach, leg, and ribs during in-room care. The resident was known to be resistive to care at times and required clear explanations of care activities. On the evening of the incident, a CNA observed the accused CNA running down the hall with blood on their face after answering the resident’s call light. The resident then stated they did not want that staff member in the room anymore and alleged that the CNA had punched them, which the CNA reported to the charge nurse. The charge nurse (LPN) documented only that the resident had needed changing, that the CNA reported a bloody nose and lip, and that the DON and physician were notified, but did not document the resident’s allegation, initiation of an investigation, or steps taken to protect residents. The LPN stated the resident reported the CNA had punched them, and that the CNA continued to work the remainder of the shift on another hall, with no immediate suspension or reassignment documented. Administration did not become aware of the abuse allegation until late the following morning, at which time interviews and a physical assessment were conducted. The record and interviews showed that staff did not document or implement immediate protective measures for all residents at the time the allegation was made, and the accused CNA continued to work independently with residents until the next day.
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