Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A cognitively intact resident, who is dependent on staff for toileting care, reported being physically abused by a Certified Nurses Aide (CNA) during a care episode. The resident described that while being changed by two CNAs, one CNA pushed down hard on her sternum, an area noted to be very bony and sensitive, which the resident perceived as abusive. This incident was corroborated by the resident's family member, who was informed by the resident about the rough handling and subsequently reported the concern to facility administration. The CNA who was later informed by the resident about the alleged abuse reported the incident to the facility administrator, but was not further involved in any investigation. The facility administrator, upon being notified of the incident, chose to document the event as a grievance rather than initiate an abuse investigation as required by policy. Another CNA present during the incident confirmed that the resident was held down with arms crossed over her chest to facilitate care, acknowledging that this was not standard practice and that alternative actions should have been taken. The Director of Nursing stated that staff are not trained to restrain residents in this manner and recognized the need for further education on abuse prevention. The failure to immediately investigate the allegation as abuse and the use of physical force during care led to the deficiency.