Failure to Implement Corrective Actions After Substantiated Abuse
Penalty
Summary
The deficiency involves the facility’s failure to take appropriate corrective action following a substantiated incident of physical abuse of Resident #1 by a licensed nurse. According to staff statements and video review, LPN #200 smacked Resident #1’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Staff noted slight discoloration to Resident #1’s hand that later resolved. The facility’s five-day follow-up investigation documented that the allegation of abuse was substantiated, that the incident was captured on security camera footage, and that witnesses provided statements. The facility’s Abuse, Neglect, Exploitation policy required analyzing the occurrence, defining how care provisions would be changed to protect residents, training staff on changes made, and reporting a licensed staff member suspected of abuse to his/her licensing board. Despite the substantiated finding of abuse and the policy requirements, the facility did not provide the mandatory abuse and neglect training to staff as indicated in the five-day follow-up investigation report. The DON and Administrator verified that no abuse training was given prior to LPN #200 returning to work. Additionally, contrary to the facility’s policy that a licensed staff member suspected of abuse will be reported to his/her licensing board, LPN #200 was not reported to the LPN licensing board for the substantiated abuse and use of corporal punishment. A review of the staff roster showed that LPN #200 remained employed at the facility and continued to work on the Alzheimer’s unit following the incident.
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