Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse in two separate incidents involving certified nursing assistants (CNAs). In the first incident, a CNA entered the resident's room with an aerosol can of air freshener, concealed it, and sprayed it over the resident's bed, pillow, and head, despite the resident's known respiratory issues and use of oxygen. The resident had previously communicated to staff that air fresheners irritated her breathing, but her request was disregarded. Video footage confirmed the CNA's actions and the resident's immediate distress, including crying out and facial grimacing. The CNA made dismissive remarks about the odor in the room and the resident's response, and then left the room. In the second incident, another CNA was observed abruptly grabbing the resident by both shoulders and roughly repositioning her in bed. The CNA spoke to the resident in a loud and rude tone, telling her not to "do all that hollering" and did not allow the resident time to respond using her communication device. The resident, who had ALS and was dependent on staff for all activities of daily living, reported feeling that staff were often rough, rude, and did not take the time to listen to her needs. She described feeling ignored and anxious when staff did not answer her call light promptly or provide adequate time for her to communicate. Interviews with staff and facility leadership revealed a lack of awareness regarding the resident's request to avoid air fresheners and a general minimization of the incidents, with some staff characterizing the actions as poor customer service rather than abuse. The facility's policies require protection from abuse and support for resident rights, but these were not upheld in the documented incidents. The resident's representative also reported bringing video evidence of the abuse to facility administration, but no action was taken at that time.