Failure to Implement Abuse Policy and Report LPN After Substantiated Abuse
Penalty
Summary
The deficiency involves the facility’s failure to correctly implement its Abuse, Neglect, Exploitation policy following a substantiated allegation of physical abuse toward a resident. According to staff statements and video review, an LPN smacked a resident’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Staff reported that there was slight discoloration to the resident’s hand, which later resolved. The facility’s policy required analyzing the occurrence, defining how care provisions would be changed to protect residents, training staff on changes made, and demonstrating staff competency, as well as reporting a licensed staff member suspected of abuse to his or her licensing board. Surveyors found that the facility substantiated the allegation of abuse and documented that the incident was captured on security camera footage and that witnesses provided statements. The five-day follow-up investigation report indicated that the perpetrator was to be terminated and that mandatory nurse training on abuse and neglect would be scheduled. However, the LPN involved remained employed and was reinstated to work on the Alzheimer’s unit. The DON and Administrator confirmed that no abuse training was provided to the LPN prior to returning to work, and the DON acknowledged that the LPN was not reported to the appropriate licensing board despite the substantiated abuse and use of corporal punishment, contrary to the facility’s written 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.