Failure to Remove Accused Staff From Resident Contact After Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policies by not immediately removing from resident contact two staff members who were accused of abuse. For one cognitively intact resident with HTN, PVD, and hypothyroidism, the care plan and facility policy required immediate suspension and removal from the facility of any employee identified as an aggressor, with prompt notification of the abuse coordinator. On one date, this resident reported that a CNA had been rough, grabbed her wrist, twisted her arm, and pressed fingers into her ankle. The CNA reported to an LVN that the resident had accused her of abuse, and the LVN changed the CNA’s assignment so she no longer directly cared for the resident. However, the CNA remained in the facility and was assigned to care for the resident’s two roommates, requiring her to enter the same room, during which the resident cursed at her and attempted to block the doorway. Nursing staff did not further question the CNA or the resident about the allegation at the time of the assignment change. A second deficiency involved a severely cognitively impaired resident with aphasia and total dependence for ADLs, whose care plan also required immediate suspension and removal of any staff member accused of abuse. The resident’s family member reported that during a night shift, an LVN entered the room in the dark, put her hand under the resident’s sheet, touched the resident’s diaper area, bent over and whispered something in his ear, and then left the room, apparently unaware the family member was present. Later that night, using a letter board, the resident told the family member that a nurse had touched him inappropriately and identified the same LVN when she returned to the room. The family member reported this allegation to another LVN, who stated he would report it to the RN. In response to the family member’s concerns, the LVN accused of inappropriate touching reported that the family member had yelled at her to get out of the room, and the RN reassigned the LVN to care for other residents. The RN later acknowledged she was aware of the facility’s abuse policy and that, after being informed of the allegation that the LVN had inappropriately touched the resident’s private area, she only changed the LVN’s assignment instead of sending her home. The DON and Administrator both stated that when there is an allegation of abuse against staff, the staff member should be suspended and removed from resident contact until the investigation is completed, and the written policy specified that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete. Despite this, both the CNA and LVN remained on the premises with potential access to other residents after abuse allegations were made.
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