Failure to Timely Report and Act on Witnessed Verbal and Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and respond to witnessed verbal and physical abuse incidents, allowing the alleged perpetrator to continue providing resident care. Facility policy required that when abuse was identified, the facility immediately protect residents from additional abuse, begin an investigation, and initiate reporting through the shift supervisor or charge nurse. On the date in question at approximately 4:00 PM, a CNA witnessed another CNA handle a resident roughly, spray perfume on the resident when they were combative with care, and make a verbally abusive statement. The witnessing CNA reported the incident to the RN supervisor, but the RN supervisor did not assess the resident and did not initiate the required abuse reporting and investigation process at that time. Resident #1 had diagnoses including aphasia, hemiplegia, and anxiety disorder, with severely impaired cognition and dependence on substantial to maximal assistance for most ADLs. Around 4:00 PM, two CNAs were providing care when the resident became combative. One CNA reported seeing, and another smelling and partially seeing, the alleged perpetrator CNA spray perfume on the resident’s clothes multiple times, and one CNA heard the verbally inappropriate comment about another resident possibly dying on the commode. The witnessing CNA reported the incident to the RN supervisor before supper and informed the supervisor that another CNA also needed to speak with them. The RN supervisor, who usually worked on the hospital side, acknowledged being aware of the report and that another CNA wanted to speak, but did not complete an incident report, did not fully interview all witnesses, and left the shift at 7:00 PM without following up. The DON was not notified until approximately 7:49 PM by an LPN who learned of the incident around 7:30 PM, and the alleged perpetrator CNA was not suspended until approximately 8:00 PM. During the period between the initial 4:00 PM report and the 8:00 PM suspension, the alleged perpetrator CNA continued to have access to residents and was involved in a second incident with another resident after supper. Resident #2 had osteoarthritis and Alzheimer’s disease, with severely impaired cognition, wheelchair use, lower extremity impairment, and dependence for mobility. After supper, a CNA reported that the same CNA was rough with Resident #2 while putting them to bed and told the resident they were not going to play the “up and down game” all night. This was reported by the CNA to an LPN, who did not escalate the concern to a nursing supervisor because they believed the behavior was only verbally inappropriate and similar to how many CNAs spoke, and they stated there was no supervisor available after the RN supervisor left at 7:00 PM. The DON later documented being notified of the incident involving Resident #2 at 7:49 PM, and the Administrator acknowledged that the incidents involving both residents were not reported to the DON until about 8:00 PM, contrary to the facility’s abuse reporting policy. The surveyors found no documentation that the 4:00 PM witnessed incident with Resident #1 or the after-supper incident with Resident #2 were reported immediately to a nursing supervisor or the Administrator as required. Interviews with the Administrator, DON, RN supervisor, CNAs, and LPNs confirmed delays in reporting, incomplete follow-up by the RN supervisor, and continued resident access by the alleged perpetrator CNA until suspension at approximately 8:00 PM. The facility’s failure to timely report and act on these abuse allegations, and to immediately protect residents from further potential abuse, was cited as Immediate Jeopardy and Substandard Quality of Care affecting all residents in the facility.
Removal Plan
- All staff currently working in the facility have been educated on abuse, identification of abuse, and reporting of abuse.
- Provide education to any staff on leave prior to the start of their shift.
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