Failure to Investigate and Report Alleged Abuse and Protect Resident
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to support each resident’s highest practicable well-being, as required by its Administration-Management policy. The incident centers on a resident with non-Alzheimer’s dementia, muscle weakness, difficulty walking, and severely impaired cognition, who was observed on facility video surveillance ambulating with an unsteady gait, holding onto hallway handrails, and moving a PPE cart into other residents’ rooms. A CNA followed the resident into a room, then was seen on video pulling the resident by the arm into the hallway, holding the resident under the left armpit, and pulling the resident up the hallway toward the wheelchair while the resident resisted. The CNA then placed the resident on the edge of the wheelchair, continued to hold under the left armpit, grasped the resident by the pants, and dragged the resident fully into the wheelchair, pushing and holding the resident’s upper body forward while moving a hand back and forth at the resident’s lower back, causing the resident’s body to jerk forward. A visitor was seen in a nearby doorway observing and gesturing during this interaction. Later that day, the visitor reported to the DON that they had a verbal altercation with the CNA and that the CNA had been disrespectful, and also stated they heard a commotion and came out to see the CNA attending to the resident. The facility’s internal summary characterized the CNA’s actions as an immediate assistance back to the wheelchair using a compact pivot transfer to maintain safety. The DON and Assistant Administrator reviewed the surveillance footage but stated they did not identify the CNA’s actions as abusive, excessively rough, or causing harm, and the CNA denied abuse. The DON directed an RN Supervisor to assess the resident, who was found sitting on the bed smiling, in good spirits, with no visible injury and no complaints of pain or discomfort. Despite the visitor’s report and the video evidence of the CNA pulling, dragging, and forcefully repositioning the resident while the resident resisted, facility administration did not treat the situation as an allegation of abuse requiring immediate investigation and protection of residents from further potential abuse. The CNA was suspended for one day for poor customer service and reassigned to another unit, but the facility did not initiate an abuse investigation at that time and did not report an alleged abuse incident to the New York State Department of Health within two hours of the allegation. The formal investigation into the abuse allegation was not initiated until after a state surveyor went onsite, and the facility did not report the allegation to the Department of Health as required, constituting a failure to administer the facility in accordance with regulatory requirements and its own policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.