Failure to Protect Resident from Abuse and Inadequate Intervention for High-Risk Behaviors
Penalty
Summary
The facility failed to protect a resident's right to be free from physical, verbal, and psychological abuse, and did not adequately identify, correct, or intervene in situations where abuse and neglect were more likely to occur. The resident, who had a history of PTSD, adjustment disorder, and anxiety, reported being forced to receive care from a CNA whom he described as rough, verbally abusive, and dismissive of his right to refuse care. The resident sustained skin tears and bruising on his arms, which he attributed to an incident with the CNA. Documentation and interviews confirmed the presence of these injuries, and staff notes indicated the injuries occurred after the staff member grabbed the resident's arms during care. Multiple staff interviews revealed a pattern of the resident expressing distress and making allegations of rough or abusive care, particularly involving male and African American CNAs. Staff acknowledged the resident's history of trauma and his tendency to refuse care or become agitated, but there was a lack of specific interventions in the care plan to address these behaviors or to guide staff responses. The Social Services Director admitted to not following up on reports of the resident's discomfort with certain staff and not referring him to psychiatric services as might have been indicated. The Risk Manager and other staff were unaware of the resident's trauma history and did not review or update the care plan accordingly. The facility's policies required the prevention of abuse and the implementation of individualized interventions for residents with behaviors that might lead to conflict. However, the care plan for the resident only included general interventions and did not specify actions for staff to take when the resident was yelling, refusing care, or expressing distress. Staff interviews indicated that expectations for handling such situations were unclear, and there was no evidence that the facility had ensured staff were trained or prepared to manage the resident's specific needs. This lack of individualized planning and intervention contributed to repeated incidents where the resident felt threatened, was injured, and reported abuse.