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F0600
D

Physical Abuse of Resident by CNA

San Gabriel, California Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A certified nurse assistant (CNA) assigned to provide one-to-one monitoring for a resident with severe cognitive impairment engaged in physical abuse. The resident, who had diagnoses including delirium, depression, dementia, and mood disorder, required varying levels of assistance with daily activities and was noted to have severe impairment in decision-making abilities. On the day of the incident, the CNA grabbed the resident's shirt from the back, causing the shirt to choke the resident at the neck area as the resident stood up from a chair. Following this, as the resident turned and threw a cup of water at the CNA's face, the CNA responded by slapping the resident's back with a loud smacking noise. Multiple staff members, including two other CNAs and the facility administrator, witnessed the incident. The administrator also reviewed surveillance video, which confirmed that the CNA grabbed the resident's shirt and slapped the resident's back. Staff interviews indicated that such physical actions are not permitted, even in response to resident aggression. The facility's policy on abuse, neglect, and exploitation clearly states that residents have the right to be free from abuse, including physical abuse, and that staff are to be adequately prepared for caregiving responsibilities, especially for residents with behavioral or cognitive issues. The CNA's actions were in direct violation of this policy, as confirmed by the administrator and corroborated by video evidence and staff testimony.

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