Failure to Timely Investigate Abuse Allegation and Remove Alleged Perpetrator from Duty
Penalty
Summary
The deficiency involves the facility’s failure to timely investigate an allegation of abuse and to prevent the alleged perpetrator from working with the alleged victim in accordance with its abuse policy. The facility’s Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigation – F609 policy required that all reports of resident abuse be thoroughly investigated by management, that the alleged perpetrator and victim be kept apart, and that the alleged perpetrator be placed on leave until the investigation was completed. An initial incident report documented that on 01/27/26, facility staff were informed by a family member of an alleged act of abuse against Resident #10, and that the family member identified CNA #1 as the alleged perpetrator. The Director of Nursing (DON) stated they learned of the accusation during a care plan meeting on 01/27/26. Despite this knowledge, facility records showed that CNA #1 continued to work at the facility on 01/29/26, 01/30/26, and 01/31/26, after the DON had been made aware of the allegation and before the administrator began the investigation on 02/03/26. The incident report also showed the administrator did not report the incident to the state survey agency and local law enforcement until 02/03/26. The administrator stated they first learned of the allegation against CNA #1 on 02/03/26 during a morning staff meeting with the DON, at which time they suspended CNA #1 and initiated the investigation. The DON later acknowledged that CNA #1 had not worked since 01/31/26 and stated they should have begun the investigation when they first learned of the allegation and immediately suspended the nurse aide.
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