Failure to Protect Resident from Rough Handling and Abuse by CNA
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was not protected from abuse by a certified nursing assistant (CNA). The resident, who had a history of lack of coordination, anxiety disorder, and type 2 diabetes, was handled roughly by the CNA during care. According to witness statements and record review, the CNA removed the resident's shirt aggressively, causing the resident to slam back into her wheelchair, and then transferred the resident to the bed in a rough manner that shook the bed. The resident was heard repeatedly saying "No" and "Stop" during the incident. A housekeeper witnessed the event from outside the room and reported that the CNA was aggressive in removing the resident's clothing and transferring her to the bed. The housekeeper also noted that the resident was not very verbal but was clearly expressing distress during the incident. The witness did not observe the resident striking out at the CNA, despite the CNA's claims that the resident was combative. The incident was reported to the charge nurse immediately after it occurred. Interviews with facility leadership revealed that both the Director of Nursing and the administrator acknowledged the CNA should have stopped providing care when the resident expressed refusal and distress. The facility's abuse and neglect policy states that residents have the right to be free from all forms of abuse, including physical and mental abuse, and that such incidents must be reported immediately. The failure to protect the resident from rough handling and to respect her expressed wishes constituted a violation of her right to be free from abuse.