Resident Abuse Incident by Certified Nurse Aide
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, or mistreatment, as evidenced by an incident involving a severely cognitively impaired resident. On the specified date, a Registered Nurse Supervisor observed a Certified Nurse Aide pushing the resident in the hallway, causing the resident to stumble backward. The Certified Nurse Aide justified their actions by stating that the resident did not listen, which was not an acceptable reason for physical contact. The resident involved in the incident had a history of severe cognitive impairment and required supervision for various activities, including eating, bed mobility, transfers, and ambulation. The resident's care plan indicated a risk for harm and abuse due to their cognitive condition and mood disorders. Despite these documented risks, the Certified Nurse Aide's actions were not in line with the facility's policy on abuse prevention, which mandates that residents must not be subjected to abuse by anyone. The facility's internal investigation confirmed the abuse allegation, as the incident was witnessed by the Registered Nurse Supervisor. The Certified Nurse Aide did not deny the action and was subsequently suspended pending further investigation. The facility's policy clearly states that residents have the right to be free from abuse, and the actions of the Certified Nurse Aide were in direct violation of this policy.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 1. What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #1 was assessed immediately to ensure that there were no injuries and emotional support was provided by RN Supervisor. A complete skin check was completed on resident #1 with no abnormal findings. Resident #1 was evaluated by the Social Worker and was unable to recall the incident due to severe cognitive impairment. Resident #1 also did not display any sign or symptoms of emotional distress. A psychology consult was also ordered for Resident #1 who was unable to recall the event and unable to engage in therapeutic interaction. Social worker has and will continue to follow up with resident to provide emotional support. Resident #1 was monitored for behavioral changes. No behavioral changes were noted. 2. How will you 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 this deficient practice. The Director of Social Services and/or designee will review and update care plans addressing the risk for Abuse for all residents with behavioral and/or cognitive impairment. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure the deficient practice will not recur, the Director of Nursing and/or designee will review the policy on Abuse/Neglect/Mistreatment- Prevention, Assessment & Reporting of these or other crimes against a resident/client in our care. Staff training and education will be provided to all staff on Abuse, Mistreatment Prevention. This education will focus on the facility responsibility to protect the resident rights and ensure residents remain from abuse. 4. 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 in practice The Director of Nursing and/or will perform random audits a total of five staff interviews weekly x 1 month and then bi-weekly x two weeks, and then monthly to ensure ongoing compliance. The Director of Social Work will perform random audits a total of five residents interviews weekly x 1 month, and then bi-weekly x two weeks, and then monthly to ensure ongoing compliance. All findings will be reported to the QAPI Committee by the Director of Nursing on a monthly basis.