Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), who was an agency staff member, physically abused a 95-year-old female resident with multiple medical conditions, including severe cognitive impairment, hypertension, chronic kidney disease, heart failure, COPD, and anxiety disorder. The resident was fully dependent on staff for activities of daily living and had no history of physical aggression. The incident took place when the CNA was providing care, and the resident's roommate, although unable to see the event due to a closed curtain, reported hearing the abuse and subsequently called for a nurse. Upon entering the room, the nurse observed the resident holding her wrist, which, when examined, showed significant bruising on both the front and back. The resident was unable to describe the event due to her cognitive impairment. The roommate also reported that the CNA threatened her, instructing her not to use the call light again. The incident was documented in the nurse's notes and an intake incident report, both indicating physical abuse and intimidation by the CNA. The facility's records and interviews confirm that the abuse was reported by the roommate, and the resident's responsible party was notified. The CNA denied the allegations, but the physical evidence and the roommate's account were documented. The facility's abuse prohibition policy requires prompt reporting and investigation of any suspected abuse or neglect, which was not sufficient to prevent this incident from occurring.