Failure to Report and Act on Resident’s Allegation of Staff Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy after a cognitively impaired resident made an allegation of staff-to-resident physical abuse. The resident had multiple diagnoses including insomnia, major depressive disorder, generalized anxiety disorder, and cognitive impairment, with a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan included interventions related to cognitive loss, the right to be free from abuse, and approaches for resistive or noncompliant behavior. Progress notes from 1/20/26 through 2/3/26 contained no documentation of any abuse allegation. During an interview, a CNA reported that approximately a week prior, the resident told her that a night-shift CNA had punched the resident in the ribs. The CNA stated she immediately informed an LPN, who allegedly responded that he did not want to get involved, and the CNA did not report the allegation to anyone else. The CNA believed the alleged perpetrator was another CNA who worked overnight and had previously received a written warning related to resident care. When interviewed, the resident initially had difficulty recalling the incident but then stated they had received a couple of punches from a staff member and indicated that the CNA probably knew who the perpetrator was. Other staff described the resident as confused but not known to make false accusations. Facility leadership, including the DON and LNHA, stated that staff were required to immediately report any abuse allegations to a supervisor so an investigation could be initiated and that staff accused of abuse should be suspended to protect residents. They reported being unaware of the allegation until informed by the surveyor and confirmed that the CNA should have reported the allegation beyond the LPN. Review of the facility’s Abuse Prevention Program policy showed requirements to protect residents from abuse, train staff on identification and reporting of abuse, and identify, assess, investigate, and report all possible incidents of abuse, which were not followed when the initial allegation from the resident was not promptly and fully reported or acted upon.
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