Resident Abuse Due to Excessive Force by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by video footage showing multiple staff members using excessive force while providing care. The resident, who was readmitted with diagnoses including cerebral vascular accident, hemiplegia, and impairments to both upper and lower extremities, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident was identified as a high-risk victim of abuse due to their inability to communicate needs effectively and vulnerability from cognitive and physical disabilities. The abuse incidents were captured on video, showing staff members handling the resident roughly and using unnecessary force. Specific instances included a CNA forcefully removing the resident's gown and wiping their face roughly, another CNA attempting to reposition the resident in bed by pulling and tugging on their upper body and head, and a resident assistant physically smacking and flicking the resident. These actions were reported to the Director of Nursing, who, upon reviewing the footage, suspended and subsequently terminated the involved staff members.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 1. Resident #1 potential victim of abuse care plan was updated as a victim of abuse, which addresses ways to ensure that he does not become a victim of abuse including but not limited to redirecting him away from persons of concern, observing whereabouts of resident and intervening as needed and monitoring socialization. The three staff members have been terminated based on the findings of the investigation. The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. 2. The Director of Nursing or designee will audit by 1/31/25 to ensure all residents at risk to be a victim of abuse have care plans in place, updated, and accurate reflecting their potential to be a victim. Any findings of noncompliance will be corrected immediately. 3. The Director of Nursing or designee will educate by 1/31/25 all licensed nursing staff on the Care Plan policy. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change the Abuse education from upon hire and annually, to upon hire and quarterly going forward. 4. The Director of Nursing or designee will audit all potential to be a victim care plans monthly for 3 months to ensure that all residents have appropriate and up-to-date care plans in place, with any findings of noncompliance corrected immediately. The Administrator and Director of Nursing will review the Abuse policy and procedure quarterly. The Director of Nursing or Designee will audit staff Abuse education compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing or Designee