Resident Harmed Due to Rough Treatment by CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, resulting in actual harm to a resident. The incident involved a Certified Nurse Aide (CNA), identified as Employee 1, who was responsible for providing care to a resident with chronic congestive heart failure and B-cell lymphoma. The resident required assistance with toileting and had a potential for bleeding complications due to anticoagulant use. During care, Employee 1 was reported to have been verbally aggressive and physically rough, leading to skin tears and bruising on the resident's left hand, forearm, and shin. The incident was witnessed by another CNA, Employee 2, who intervened and reported the mistreatment to the Licensed Practical Nurse (LPN) and Registered Nurse (RN) supervisor. Employee 2 described Employee 1's behavior as inappropriate and aggressive, noting that the resident was very weak and had difficulty standing. The resident expressed feeling scared and shaken after the incident, and the skin tears were observed to be bleeding and of significant size. The RN supervisor and Assistant Director of Nursing (ADON) were informed of the incident, and the resident was assessed to have additional bruising and was later hospitalized due to a decline in condition. The resident's roommate corroborated the account of rough treatment, describing Employee 1 as rude and impatient. Despite having received abuse prevention training, Employee 1's actions resulted in physical and emotional harm to the resident.
Plan Of Correction
1. The facility implemented quick and decisive action in accordance to our abuse policy upon abuse allegations from Resident 1 regarding Employee 1. Employee 1 was immediately suspended, and RN performed a skin check on Resident 1, the provider was notified, and statements were obtained. Within 24 hours the Department of Health was notified, the police department was notified and intent to press charges occurred; the Cumberland County Office of Aging was notified as well as the Pennsylvania Department of Aging. Resident 1 was immediately tended to by staff regarding his skin tears and first aide was administered appropriately. 2. The facility will continue to perform weekly skin checks on remaining residents, observe the grievance policy, and conduct routine care plan meetings in order to determine any other residents who may be at risk for similar issues. We did interview other residents on Employee 1 assignment and no other residents had complaints. 3. The facility provides annual mandatory abuse training to all staff with the most recent training having been completed in October of 2024. The facility conducted immediate retraining of all staff upon receiving the complaint of abuse and will increase the abuse training from annual to quarterly x 12 months to ensure all staff receive the appropriate training and understand such training. 4. The facility will continue to follow the abuse policy, will continue to perform background checks prior to hire, will continue to perform reference checks prior to hire, will continue to perform annual performance evaluations for all staff, will continue to monitor grievances submitted by residents and family for the potential for abuse, will continue to perform weekly skin checks of all residents, and will continue with routine care plan meetings with residents and family to ensure any indication of potential abuse is investigated and handled appropriately. The Director of Nursing or designee will review all grievances submitted to ensure appropriate investigation and follow up continue. The audits will include 5 random grievances weekly x 4 weeks then 5 random grievances monthly x 2 months. Findings will be discussed at QAPI. 5. Date of Compliance: 2/10/25.