Staff-to-Resident Verbal and Physical Abuse During Improper Transfer
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, anxiety, depression, muscle weakness, and impaired mobility was subjected to staff-to-resident verbal and physical abuse during a transfer. The resident required maximum assistance for activities of daily living and had a care plan specifying the need for two staff members for transfers, as well as interventions to address behavioral symptoms such as agitation and combativeness. Despite these documented needs, a CNA attempted to transfer the resident alone, disregarding both the care plan and the resident's expressed refusal to go to bed. During the incident, the CNA used a bear hug technique to forcibly transfer the resident, despite objections from both the resident and other staff present. The resident became agitated, resisted the transfer, and bit the CNA. The CNA responded with threatening and inappropriate language, stating, "Bite me again, I will bite you back, I'll go to jail I don't care," and continued to attempt the transfer alone. The transfer was performed forcefully, resulting in the resident being thrown onto the bed and sustaining a skin tear on the left wrist. Witnesses reported that the CNA ignored suggestions to leave the resident in his chair and did not follow the recommended approach for managing the resident's behaviors. Multiple staff members witnessed the incident and reported that the CNA's actions were abusive, both verbally and physically. The resident was left with a skin tear and bruising, and the incident was subsequently reported to facility leadership. The CNA was not assigned to the resident's unit and was not requested to assist with the transfer. The facility's abuse policy required immediate reporting and removal of implicated staff, but there was a delay in notification to the Director of Nursing and Administrator.