Failure to Protect Resident from Abuse and Maintain Dignity
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) placed her fingers in the face of a female resident with significant cognitive impairment, including Alzheimer's disease, cerebral infarction, anxiety disorder, dysphagia, and schizophrenia. The resident was rarely understood, usually understood others, and required moderate to total assistance with daily activities. The incident was captured on video by a family member, who later reported feeling disturbed after viewing the footage. The video showed the CNA repeatedly putting her fingers in the resident's face while preparing to provide incontinent care, which visibly agitated the resident and led her to attempt to bite the CNA's fingers. Interviews with facility staff, including the Interim Director of Nursing (DON), Regional Director of Clinical Services, and other nursing staff, confirmed that the CNA's actions were inappropriate and could affect the resident's dignity. The CNA herself admitted to being playful with the resident and acknowledged that her behavior was not appropriate, especially after learning of the resident's dementia diagnosis. Staff members interviewed agreed that placing fingers in a resident's face was not acceptable and could impact the resident's dignity. Facility policy reviews indicated that residents have the right to be free from abuse, neglect, and to be treated with respect and dignity. The actions of the CNA were inconsistent with these policies, as confirmed by both the video evidence and staff interviews. The incident demonstrated a failure to protect the resident from actions that could cause mental anguish or emotional distress, as required by facility policy and resident rights.