Failure to Immediately Report and Act on Allegation of CNA Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was immediately reported to the Nursing Home Administrator and/or Grievance Officer, as required by its Abuse, Neglect, and Exploitation policy. The policy states that all alleged violations must be reported to the Administrator and appropriate agencies immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It also requires immediate response to protect the alleged victim and ensure residents are protected from physical and psychosocial harm during and after investigations. Despite these written procedures, the allegation involving a CNA and a resident was not promptly reported to the Administrator, and the CNA was not immediately removed from resident care areas. The resident involved had a Quarterly MDS showing a Brief Interview for Mental Status score of 9, indicating severely impaired skills for daily decision-making, and a Patient Health Questionnaire score of 6, indicating mild depression. The resident had no upper extremity range of motion impairment, but had lower extremity range of motion impairment bilaterally, and was independent with eating, dressing, and mobility, with supervision for showers and set-up for transfers. On the day of the incident, a CNA (CNA-D) reported that another CNA (CNA-E) reacted to a verbal exchange with the resident by referring to the resident in derogatory terms, manipulating the resident’s food with bare hands, and spitting on the food on the resident’s lunch tray, then stating an intention to watch the resident eat the contaminated food. CNA-D confirmed that the resident was not stopped from eating the food. After witnessing the incident, CNA-D reported it to an LPN (LPN-F) at the nurse’s station after lunch. While they were at the nurse’s station, CNA-E approached and stated, “Guess what? She ate it.” The facility’s Nursing Home Resident Mistreatment, Neglect, and Abuse Report later documented that the Administrator was notified on the date of the incident, but the Misconduct Incident Report and time records showed that CNA-E continued working until the end of the shift and into part of the next shift, and also returned to work the following day before being suspended. The Administrator confirmed that the allegation was reported at the end of the shift and acknowledged that the facility’s abuse policy and procedure were not implemented, as the allegation was not immediately reported and the CNA was not promptly removed from resident care areas. No additional explanation was provided by the facility for the delay in reporting, which allowed the CNA to remain on duty and continue to have contact with the resident and other residents.
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