Failure to Immediately Protect Resident After Initial Staff-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to immediately protect a resident from staff-to-resident abuse in accordance with its abuse prevention and management policy. The facility’s policy required immediate protection of any resident upon identification of suspected abuse, including immediate suspension of the suspected employee, prompt initiation of the reporting process by the shift supervisor, and immediate examination and notification by the DON or designee for reports of physical or sexual abuse. The policy also stated that when abuse is identified, the facility must take all appropriate steps to remediate noncompliance and protect residents from additional abuse immediately, and that investigations must begin immediately upon notification while preventing further potential abuse. Resident R1, who was cognitively intact with a BIMS score of 15 and had a diagnosis of Major Depressive Disorder, reported that a nurse aide (Employee E4) verbally, physically, and mentally abused the resident. During the investigation of a physical abuse incident that occurred on February 23, 2026, it was determined that there had been a prior verbal abuse incident between the same nurse aide and the same resident on February 21, 2026. The earlier incident was substantiated as abuse, and the resident had reported that the aide always argued with the resident. The facility was unable to provide a written investigation related to the February 21, 2026, incident. Interviews with the DON and the Nursing Home Administrator revealed that neither was informed of the February 21, 2026, verbal abuse incident at the time it occurred. The DON stated that she only became aware of the February 21 incident while investigating the February 23 physical abuse incident, and confirmed that the first incident was not reported in a timely manner. Both the DON and the Administrator confirmed that the aide continued to work after the February 21 incident and was not suspended until after the later physical abuse incident was reported. As a result, the facility did not implement its own policy requirements for immediate reporting, investigation, and protection of the resident following the initial substantiated abuse incident.
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