Failure to Remove Accused Staff and Thoroughly Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough abuse investigation and to follow its own abuse policy after a resident alleged physical abuse by a CNA. The facility’s F600 policy requires that when abuse is observed or suspected, the resident is made safe, the incident is immediately reported to a supervisor, the DON and NHA are notified, and the accused staff member is removed from the premises and suspended from work until the investigation is concluded. The policy also calls for interviews of the accused, the resident, witnesses, and others as needed, and specifies that when a staff member is suspected, they will be sent home and not allowed to return to work unless the investigation demonstrates they are not guilty of abuse or misappropriation. The resident involved is an older adult with vascular dementia, generalized anxiety disorder, weakness, and legal blindness, with a BIMS score of 9 indicating moderate cognitive impairment. The resident requires partial to maximal assistance with mobility and is dependent on staff for toileting hygiene and transfers, with frequent urinary incontinence and constant bowel incontinence. According to the facility’s self-report, at approximately 12:30 AM, a CNA was performing cares when the resident alleged the CNA pushed them against the wall and the bar of a Sara Steady and slapped them in the face six times with a wet rag. An RN documented that the resident reported pain but showed no swelling, redness, or bruising on assessment. The CNA reported that the resident alleged the CNA hit them, and the CNA stated she attempted to get the nurse but did not leave the room because the resident was attempting to self-transfer. Despite the facility’s policy requiring immediate removal and suspension of the accused staff member during an abuse investigation, the CNA continued to work with other residents after the abuse allegation during that same shift, although she did not continue to care for the alleging resident. The RN who was notified of the allegation continued cares for the resident for the remainder of the shift and reported the incident to the day shift nurse and the night shift supervisor, but stated she was not clear with the night shift supervisor that it was an allegation of abuse and initially viewed it as confusion rather than abuse. The Director of Social Services later learned of the allegation during morning rounds when the resident reported being hit with a rag and then notified the NHA and DON. The surveyor confirmed that the CNA continued to work after the allegation and the DON acknowledged concerns about this, demonstrating that the facility did not fully implement its abuse policy to protect residents during the investigation.
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