Failure to Immediately Remove Alleged Perpetrator After Abuse Allegation
Penalty
Summary
The facility failed to immediately protect a resident from potential further abuse after an allegation against a CNA. An admission assessment for Resident #1, who had dementia, severely impaired cognition with a BIMS score of 03, and was dependent on staff for transfers and wheelchair use, documented the resident’s condition. An incident report showed that on 02/11/26 at approximately 11:00 p.m., an allegation of abuse by CNA #1 toward Resident #1 occurred, but RN #1 did not report the allegation to the DON until 6:00 a.m. on 02/12/26. During this time, CNA #1 was not removed from duty and was allowed to continue working, as confirmed by a timesheet showing CNA #1 clocked out at 6:15 a.m. on 02/12/26. The facility’s undated Patient Abuse policy stated that to protect the resident during an abuse investigation, the employee would be suspended during the investigation process. RN #1 stated they did not send CNA #1 home after witnessing the abusive behavior and did not know the facility’s abuse procedure, waiting until the next morning to report the allegation. The DON stated CNA #1 should have been sent home immediately and should not have been allowed to finish the shift. This sequence of events demonstrates that the facility did not follow its own abuse policy and failed to immediately remove the alleged perpetrator from resident care after an abuse allegation involving Resident #1.
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