Resident Abuse Incident During Showering
Penalty
Summary
The facility failed to ensure that a resident was free from abuse during a showering incident. A Certified Nurse Assistant (CNA) and a Registered Nurse (RN) were assisting the resident in the shower room when the resident kicked towards the CNA. In response, the CNA reflexively smacked the resident's upper right leg with an open hand to push the leg away. The RN was startled by this action and immediately reported the incident to the supervisor. The facility's policy on abuse prohibition emphasizes protecting residents from abuse, neglect, and mistreatment, but this incident indicates a lapse in adherence to that policy. The resident involved in the incident was admitted with severe cognitive impairment, affecting their ability to make decisions regarding daily living tasks. Prior to the incident, the resident was assessed as being comfortable with stable vitals and no signs of distress or injury. Following the incident, a thorough examination revealed no physical injuries or changes in the resident's condition, indicating that the action did not result in physical harm. However, the incident itself constituted a breach of the facility's abuse prevention policy. Interviews conducted during the investigation revealed that the CNA involved was not typically assigned to the resident and was covering due to staffing shortages. The CNA described the action as a reflexive response to being kicked, with no intention to harm. The Director of Nursing acknowledged the reflexive nature of the CNA's response but emphasized the importance of adhering to training and protocols to prevent such incidents. The facility's internal investigation documented the incident and led to the suspension and eventual termination of the CNA involved.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 1) CNA #1 was immediately removed from the unit, interviewed, and investigative statements obtained, followed by immediate suspension pending completion of the investigation. Resident was promptly assessed by the Nurse supervisor and noted to have no redness or marks to his body including upper right leg. No sign of discomfort, upset, or change from baseline status was seen. A comprehensive investigation was initiated that included review of policy and procedure, interview of staff, review of surveillance footage, and medical record. It was confirmed that CNA #1 had participated in multiple trainings on Abuse since date of hire 8/5/24. CNA #1 was initially trained in the abuse prohibition policy on date of hire 8/5/2024 as well as Care of Cognitively Impaired Residents on 8/12/2024 and Response to Abuse of Residents on 8/24/2024. In addition, CNA #1 completed follow-up training on Abuse, Neglect, and Mistreatment on 9/20/2024. Since that time, she received and reviewed monthly newsletters that contained ongoing education on various aspects of the Abuse Prohibition Policy. On investigation, CNA #1 was tearful and remorseful. She indicated over and over, “I would never hurt him, I thought I was going to be kicked and I just reflexively reached out to prevent it.” Resident is noted to have unpredictable non-purposeful movements especially during bathing. His plan of care was updated to include strategies during shower and ADL care as well as behavioral strategies to address these movements and to support the resident during ADL care. CNA #1 was terminated upon completion of the investigation. Residents’ parents were notified; investigative findings as well as corrective actions were reviewed. The parents were satisfied and appreciative of the update. 2) To protect residents at risk, the facility will continue to monitor, through daily morning report review, behavior health rounds, care plan meetings, and occurrence report reviews, for any changes in condition, changes in behavior, or injuries of unknown origin. All identified changes will be subject to the investigative process. In addition, quarterly Psychosocial assessments have been updated to include an enhanced list of risk factors and interventions that will guide comprehensive care planning, referrals to the Behavioral Health team, and indicated staff training. An initial review of all 122 residents was conducted by the interdisciplinary team which identified a total of 8 residents with similar behaviors during care. ADL care plans were updated with new interventions and behavioral care plans updated and in 4 cases, initiated. 3) To reduce the risk of further occurrences, all staff including but not limited to direct care staff and ancillary staff will be re-inserviced. Education will focus on all aspects of the Abuse Prohibition Policy as well as managing residents with aggressive/active and non-purposeful movements. Education will include didactic presentations, online learning exercises, competency-based training, staff meetings, and/or monthly newsletters. 4) The Director of Nursing will monitor ongoing compliance rates of all departments to the successful completion of quarterly educational efforts related to abuse prevention. Compliance rates will be monitored using an audit tool that will calculate compliance rates for quarterly training. The Director of Nursing will conduct the audits and report in writing, at least quarterly, to the Administrator and Quality Committee, the findings and any corrective actions for a period of not less than 18 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 1/21/2025 by the Director of Nursing.