Failure to Timely Report and Protect Resident After Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to respond timely and appropriately to an allegation of abuse and to protect a resident from further potential abuse once staff became aware of the allegation. Facility policy required any employee who witnessed abuse to immediately intervene to stop the abuse, report it at once to a supervisor or charge nurse, and ensure the alleged abuser was removed from resident care while an investigation was conducted. On the date of the incident, a physical therapy assistant (PTA) observed an interaction between a certified nursing assistant (CNA) and a resident in which the CNA allegedly used profanity, forcefully removed the resident’s blanket, pulled the resident’s leg, and yanked the resident up by the wrist before placing the resident into a wheelchair. The PTA reported that the resident appeared fearful and stated that the CNA behaved that way “all the time,” but the PTA did not intervene during the incident and did not immediately report the allegation. The resident involved had diagnoses including muscle weakness, cerebral infarction, and diabetes, with a recent MDS documenting moderately impaired cognition and a need for staff assistance with bed mobility and transfers. Despite the PTA’s report to an LPN sometime after lunch, and the LPN’s subsequent report to the Human Resources (HR) Director that afternoon, the allegation was not promptly escalated to the DON or Administrator on the day of the incident. Timecard and assignment records showed that the CNA continued to work a full day and evening shift on the day of the alleged incident and was again assigned to the same resident the following morning, indicating that no immediate protective measures, such as removing the CNA from resident care, were implemented upon initial staff awareness of the allegation. The facility’s internal investigation, completed several days later, concluded there was no evidence to support that abuse had occurred and included statements from the PTA, the CNA, the resident, and the resident’s roommate, who described the CNA’s interaction as abrupt. However, the investigation lacked documented statements from the LPN and the HR Director, even though both were identified as having knowledge of the allegation. Interviews with the DON, Administrator, Regional Social Worker, and other staff confirmed that there was a delay in reporting the allegation to facility leadership, that the investigation was not initiated on the day of the incident, and that there was a breakdown in communication that resulted in the CNA continuing to provide care to the resident after the alleged incident without immediate protective actions being taken.
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