Failure to Protect Resident from Staff Abuse and Inadequate Incident Reporting
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by staff. The incident involved a resident with neurogenic bowel, neuromuscular dysfunction of the bladder, psychoactive substance abuse, and hepatitis C, who was cognitively intact per assessment. The resident was asleep when two CNAs attempted to wake him by talking loudly, smacking the bed, and using his bamboo back scratcher to touch his lip and possibly his stomach. The resident was startled and responded by throwing water on one of the CNAs. The CNA then brought another staff member into the room to scold the resident and threatened to report him for his actions. An LPN was present at the doorway and later at the foot of the bed during the incident. The facility's investigation substantiated the abuse allegation based on the resident's account and staff interviews. The CNAs admitted to using physical means and loud voices to wake the resident, which deviated from standard practice. The former Administrator described the incident as "one aide aggravating a resident" and acknowledged prior playfulness between the staff and the resident. The facility also failed to report the incident to the State Survey Agency or other required agencies as mandated.