Neglect and Verbal Mistreatment by CNAs
Penalty
Summary
Multiple residents were subjected to neglect and verbal mistreatment by two certified nursing assistants (CNAs), identified as Staff A and Staff B. Residents reported being left in soiled briefs for extended periods, not being cleaned properly during care, and being spoken to in a disrespectful and demeaning manner. One resident, who was dependent on staff for all activities of daily living due to significant physical and cognitive impairments, described being left saturated with menstrual blood and not being wiped during care. This resident also reported that the CNAs made derogatory comments about her and other residents, including discussing their weight and making negative remarks about their children. Other residents corroborated these accounts, stating that the CNAs were rude, did not provide timely assistance, and made them feel like burdens when they requested help. Additional residents described similar experiences, including being left soiled, not being repositioned or assisted out of bed as requested, and being ignored when call lights were activated. Some residents reported that the CNAs would only change them once per shift, regardless of need, and would talk about other residents and staff in a negative manner while providing care. Staff interviews further supported these claims, with several staff members stating that Staff A and Staff B were often unprofessional, verbally aggressive, and would avoid caring for certain residents. Staff also reported that meal trays were left in front of residents for extended periods and that the CNAs would disappear during critical care times. The facility's own policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, mental anguish, or emotional distress, including not providing timely toileting and hygiene care. The policy also required staff to report any allegations of abuse or neglect immediately. Despite these policies, the behaviors of Staff A and Staff B persisted over time, affecting multiple residents on the same unit. The neglect and verbal mistreatment were corroborated by resident interviews, staff statements, and observations, indicating a pattern of failure to provide adequate care and maintain resident dignity.
Plan Of Correction
F 600 1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee. Residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns.