A certified nursing assistant used bedsheets to tie two residents with advanced dementia to chairs -- but 383 days passed before the Louisiana Department of Health added the employee to a database that alerts care facilities when someone is banned from that line of work, an audit found.
In another case, after a care worker stomped on the neck of a resident curled into the fetal position, it took the health department 679 days to add the worker to the database, according to the audit.
The incidents illustrate the risk of prolonged investigations into allegations of abuse and neglect against workers at care facilities, according to a new report released Monday by the Louisiana Legislative Auditor.
It can take months or even more than a year for the state health department to investigate allegations of abuse or neglect at care facilities like nursing homes and group homes for people with disabilities -- all while the accused stays on the job, the audit found.
Moreover, nursing facilities could unintentionally overlook instances of abuse and neglect committed by potential hires due to loopholes in state health regulations, according to the audit report, which covers a five-year span from the summer of 2018 to the summer of 2023.
The Louisiana Department of Health is charged with investigating allegations of abuse and neglect made against certified nursing aides or direct service workers, who provide care in non-nursing facilities.
Once an allegation is substantiated, that individual is barred from being a care worker, and their names are placed in a database called the "adverse actions list."
On average, it took close to 400 days from when an incident was initially reported to the health department to when it was added to that database, according to the auditor's review of a sampling of 80 abuse and neglect instances.
The shortest time was from initial complaint to database entry was 64 days, and the maximum was 951 days.
"The risk is that CNAs/DSWs with a substantiated allegation of abuse and neglect may continue to work with vulnerable populations during the time it takes for LDH to add the CNA/DSW to the adverse actions lists," the report says.
The auditor recommended LDH establish timeframes for its investigation procedures. The health department agreed, and it said it has implemented new procedures to track investigations, according to the report.
However, the health department pointed out it doesn't have enough staff to conduct the reviews in timely manner.
About 55 perpetrators per month were referred to LDH for review in the 2021 fiscal year. That increased to 73 per month by 2024. There are just one full-time and two part-time reviewers at the health department.
As of August last year, there was a backlog of 354 incidents that needed review, the health department said.
The auditor also found loopholes in rules requiring care facilities to check potential employees against the adverse actions list database.
Because investigations can take so long, care workers could be hired at a different facility before an investigation is complete and their names are added to the database.
Also, before hiring a CNA, nursing facilities are required to review a database called the "CNA Registry" -- but not the adverse actions list -- leaving open the possibility of hiring CNAs who committed abuse and neglect in previous jobs as direct service workers.
To address the loopholes, the health department will soon require nursing facilities to check both databases before hiring a CNA, and it said it agreed with a recommendation to require health care providers to run periodic database checks of its care workers.
Inconsistent procedures
The audit also accuses LDH of failing to provide guidance to its reviewers on which incidents should be deemed abuse or neglect.
Creating a formal policy or procedure would help reviewers "made consistent and fair determinations of findings," the report says.
The health department disagreed with the auditor's recommendations, however, saying that existing definitions in state offered sufficient guidance to reviewers as to when a determination of abuse or neglect is appropriate.
The audit also recommends the department add another layer of "supervisory review" before adding an incident to the database.
The health department, however, said an additional review by a supervisor is unnecessary because appeal procedures already exist. Nonetheless, it said it will test out a supervisory review process with a sample of incidents.
Audit part of a larger series
The January report comes on the heels of another audit that found deficiencies in how the Louisiana Department of Health regulates Home and Community-Based Services (HCBS) for people with developmental and intellectual disabilities. The Louisiana Legislative Auditor released that report on Nov. 27. The audit covers a five-year period, from mid-2018 to mid-2023.
People with such disabilities are at higher risk for abuse and neglect, which can include manipulation of medicine, withholding of assistive devices or a provider "who refuses to provide essential assistance," the report notes.
LDH's goal is to conduct a licensure survey of HCBS providers at least once every three years to assess compliance. But between 2018 and 2023, LDH failed to meet that goal with one-fourth of 546 providers, according to the audit,
Auditors found that 69 providers were not surveyed at all over the five-year period.
The department agreed to make improvements to meet its goal, noting that the agency's COVID-19 activities disrupted survey frequency.
Also over the five-year period, the agency "conducted 1,979 surveys addressing 5,420 separate allegations of noncompliance, with 2,194 related to abuse or neglect."
The audit found additional flaws in how the state oversees support coordination agencies with which it contracts. Such agencies employ support coordinators, who act as case workers by connecting HCBS participants to care.
Support coordinators are an important part of the HBCS system and can help detect and prevent abuse, according to the report.
But "stakeholders reported concerns regarding limited participant contact with support coordinators and potential weaknesses in agency oversight of the providers that employ them," the audits says.
It found that eight out of 36 support coordination agencies did not receive all required monitoring reviews between 2018 and 2023.
The Louisiana Department of Health told auditors it would work to improve support coordinator monitoring and is currently reviewing relevant policies and practices.