Resident Abuse Due to Inadequate Staff Training
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, neglect, or mistreatment, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively impaired and had a history of physical and verbal behaviors, was heard yelling from behind a closed door. Upon entering the room, multiple staff members observed the CNA pushing the resident, holding their arms down, and preventing them from leaving the room. Despite attempts by other staff to intervene, the CNA did not release the resident until instructed by a Licensed Practical Nurse (LPN). The resident had been admitted with various diagnoses and was documented as having daily physical and verbal behaviors, rejection of care, and wandering tendencies. The facility's care plan for the resident identified them as being at high risk for abuse and having a potential to abuse others, with interventions in place to manage these risks. However, during the incident, the CNA, who was working through an agency and had not received specific behavior management training from the facility, restrained the resident inappropriately. Interviews with facility staff revealed that agency staff, including the CNA involved, did not receive the same mandatory training on behavior management and de-escalation tactics as regular staff. The facility's policy on abuse prevention was not effectively implemented, as the CNA was not adequately trained to handle the resident's behaviors, leading to the inappropriate physical restraint of the resident. The facility's decision not to provide comprehensive training to agency staff contributed to the deficiency in ensuring the resident's right to be free from abuse and mistreatment.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Certified Nursing Assistant Number was terminated on 01/12/2025. Resident #1's potential victim of abuse care plan was reviewed and remained appropriate. The abuse policy was reviewed and did not need to be revised. The agency education policy was revised to include proper response in the event of a behavior. 2. All residents have the potential to be affected by this deficient practice. The Director of Nursing will audit all agency staff who provide cares to behavioral patients to ensure that all agency staff are trained in the appropriate response when behaviors occur. 3. The Director of Nursing or designee will educate all current and future agency staff on appropriate response when behaviors occur and the revised agency education policy. 4. The Director of Nursing or designee will audit all current and future agency staff weekly times 3 months and quarterly thereafter to ensure that they receive appropriate training in proper response to behaviors as well as to ensure that they understand the revised agency education policy. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing will be responsible for compliance.