Inappropriate and Undignified Treatment of Residents by CNA
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of Certified Nurse Aide #10 towards two residents. Resident #46, who had severe cognitive impairment due to conditions such as cerebral infarction and dementia, was subjected to undignified treatment when Certified Nurse Aide #10 made a fist and a boxing jab motion towards them. Additionally, the aide wheeled Resident #46 into a corner, leaving them facing the wall in a common area. This behavior was observed on video footage and was described as inappropriate and potentially intimidating, especially given the resident's cognitive deficits. Resident #81, who also had severe cognitive impairment due to dementia and Parkinson's disease, was similarly mistreated. Certified Nurse Aide #10 was observed pushing Resident #81 in their wheelchair with the front wheels lifted off the ground, performing a 'wheelie' motion. This action was captured on video and was considered unsafe and undignified, as it could have caused fear or harm to the resident. The comprehensive care plans for both residents indicated that they required assistance with mobility and had potential for mood or behavior alterations, necessitating a respectful and supportive approach from staff. Interviews with facility staff, including the Human Resource Manager, Certified Nurse Aide #11, Activity Leader #1, and the Director of Nursing, confirmed that the actions of Certified Nurse Aide #10 were inappropriate and did not align with the facility's dignity policy. The staff emphasized that residents, particularly those with cognitive impairments, should not be subjected to actions that could be perceived as threatening or disrespectful. The facility's policy on dignity requires that all interactions with residents focus on maintaining and enhancing their self-esteem and self-worth, which was not upheld in these instances.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #46 and #81 were both interviewed by the Director of Social Services to ensure they are being treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality at the time of the incident. Both residents appeared to have no negative impacts from the facility self-reported occurrences, which include no behaviors that would have implied they had concerns with abuse or dignity. #46 has been discharged. #81 does have cognitive impairment, and their legal representative was notified and interviewed, and no concerns were reported. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. The Director of Social Work/designee(s) will interview all residents and/or responsible representatives (if the resident is unable to participate) to ensure they are treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality. Any reports of not being treated with respect and dignity will be investigated and reported as required. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The nurse educator will re-educate all staff on the facilities Resident Rights and Dignity policy to ensure each resident is treated with respect and dignity and receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Monthly at the resident council meeting, the topic of dignity will be reported on, to maintain resident expectations for the treatment received from staff, while a resident within the facility. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Social Work/designee will conduct 15 quality of life/dignity interviews with the residents or resident representatives (3 residents per unit) for a period of 3 months. Any reports of not being treated with respect and dignity will be investigated and reported as required. Results of the interviews will be submitted to the QA committee for review. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.