Failure to Thoroughly Investigate Alleged CNA Abuse and Remove Alleged Perpetrator From Duty
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse and to act in accordance with its abuse prohibition policy after one resident reported witnessing abuse of a roommate. One resident with moderate cognitive impairment (BIMS score 9/15) reported that on a Saturday a CNA hit and pulled the hair of their roommate, who was unable to complete a BIMS due to being unable to speak or be understood. The reporting resident described the CNA as a white, heavyset female with brown hair and arm tattoos and stated that this CNA provided care to the roommate but not to them. The allegation was documented on a reportable event survey, and the facility’s summary noted that the resident reported seeing the CNA punch and pull the roommate’s hair. The facility’s response to the allegation was limited to showing the reporting resident small, headshot photos of three CNAs who fit the general description, including the CNA assigned to the alleged victim on the date in question. The resident did not identify any of the faces, later stating the photos were too small to correctly identify the perpetrator. There was no documentation of interviews with staff or other residents, and no evidence that the CNA who matched the description and was assigned to the alleged victim was suspended or removed from duty during the investigation. The DON stated she did not interview any CNA or other staff because the resident could not identify the alleged perpetrator from the photos and that she ruled out other staff based on the description. Subsequent interviews confirmed that the CNA fitting the description had been assigned to the alleged victim on the shift in question and had not been informed of any allegation, interviewed, or suspended. Other CNAs who worked that shift and one who had switched resident assignments with the implicated CNA reported they were not interviewed and stated that only this CNA matched the description given by the reporting resident. The facility’s abuse policy required immediate removal of the employee alleged to have committed abuse from duty pending investigation, initiation of an investigation within 24 hours, and thorough documentation of interviews in the risk management portal, but the investigation lacked documented staff and resident interviews and did not include removal of the alleged perpetrator from duty.
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