Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
Three residents were not protected from abuse and neglect as required by facility policy and federal regulations. One resident, who had hemiplegia, Parkinson's disease, and severe cognitive impairment, was care planned for two-person mechanical lift transfers. However, two CNAs attempted to transfer the resident using a stand pivot technique with a walker, contrary to the care plan. During the transfer, the resident's legs gave way, and the resident was lowered to the floor, later being diagnosed with a left femur fracture. Both CNAs involved did not verify the care instructions prior to the transfer, and one CNA relied on the other's familiarity with the resident rather than checking the care card. The incident resulted in actual harm to the resident. Another incident involved a resident with dementia, diabetes, and a history of aggressive behavior, who struck another resident in the eye while attempting to take a personal item. The aggressor had a documented history of psychiatric issues, including agitation, hallucinations, and poor cooperation with medication. The care plan for this resident included close monitoring and behavioral interventions, but the incident occurred in a hallway near the nurse's station without witnesses. The assaulted resident experienced mild swelling to the eye and emotional distress following the event. Staff interviews confirmed awareness of the aggressive resident's behavioral issues and the need for close monitoring. Despite these interventions, the aggressive behavior was not prevented, and the resident was able to physically harm another resident. The facility's failure to follow established care plans and ensure adequate supervision led to both physical injury and emotional harm among the residents involved.