Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse and neglect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred when the CNA was attempting to provide care to the resident, who was in a wheelchair. During this interaction, the resident became agitated, pushed against the CNA, and bit her. A Social Worker Assistant witnessed the CNA hitting the resident in response to being bitten. The Social Worker Assistant intervened, took the resident away, and reported the incident to the facility's Administrator. The resident involved in the incident had been admitted to the facility with diagnoses including major cognitive impairment and was residing in a secured unit for individuals with memory care needs. The resident's cognitive abilities were severely impaired, as indicated by a low score on the Minimum Data Set (MDS) assessment. Following the incident, the resident was unable to recall the event due to her advanced cognitive impairment but did report having pain in the area where she was allegedly hit. The facility's investigation into the incident included reviewing witness statements and interviewing staff. The CNA involved denied hitting the resident, claiming the Social Worker Assistant was lying. However, the facility's investigation concluded that the allegation of abuse was verified. The CNA was immediately suspended, and the incident was reported to law enforcement and Adult Protective Services. The resident's daughter, who is also her Health Care Surrogate, was informed of the incident and provided background on her mother's condition and care needs.
Plan Of Correction
This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The CNA was suspended on. The CNA was terminated on. The CNA was reported to the Nurse Aide Registry on. The resident was evaluated by the Psych APRN and The Care ARPN on. New orders were received for 50mg every 6 hours as needed for or. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; All residents residing in the Burroughs unit had the potential to be affected. The CNA involved worked full time on that unit only. Skin evaluations were completed on every resident on the Burroughs unit on. There were no abnormal findings indicating any type of or neglect. The CNA was suspended on and terminated on. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. All staff were re-educated on the policy and procedure, customer service and resident rights related to by the Nurse Management Team. This training was initiated on and was ongoing until all staff were completed. The completion date was. Knowledge verification was completed by administering a post test to all employees. The facility met with the QIO team on. The QIO team provided the facility with a De-escalation toolkit and provided training to the ADON, Staff Educator, DON and Administrator. The ADON completed the De-escalation training with all staff. This was completed to 27th, 2025. The staff remaining were removed from the schedule and the training is being offered every Tuesday as part of new hire orientation. The staff remaining will attend at that time and then may resume their normal working schedule. Knowledge verification was completed by administering a pre and post test to all employees who attended the training. Daily knowledge checks and audits will assess staff adherence to the education provided starting on. These will.