Failure to Protect Residents from Neglect and Mental Abuse by Staff
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to protect residents from neglect and mental abuse by two Certified Nursing Assistants (CNAs), referred to as Staff A and Staff B. Multiple residents reported being left in soiled briefs for extended periods, not being cleaned properly, and being made to feel like a burden when requesting assistance. Residents also described disrespectful and unprofessional behavior from the staff, including name-calling, derogatory comments about residents' weight and abilities, and discussing other residents and staff in a negative manner during care. These actions were corroborated by staff interviews and written statements, which described a pattern of rude, verbally aggressive, and neglectful behavior by Staff A and B, particularly when they worked together. The affected residents had significant care needs, including dependence on staff for toileting, hygiene, and mobility due to conditions such as hemiplegia, aphasia, obesity, and limb amputations. Several residents were cognitively intact and able to articulate their experiences, while others had severe cognitive impairment. The neglect included failure to provide timely and adequate personal care, such as not changing soiled briefs, not cleaning residents properly, and leaving residents unattended in the shower. Some residents reported that their call lights were ignored or turned off without their needs being met, and that they were made to wait for the next shift for care. Staff interviews revealed that the issues with Staff A and B were known among other staff members, who reported the behavior to management and described a hostile work environment. Written statements and interviews indicated that Staff A and B would avoid caring for certain residents, complain openly about their assignments, and disappear during critical care times. Despite these reports, there was a lack of effective follow-up or intervention by facility management prior to the survey, allowing the neglectful and abusive behavior to persist and affect multiple residents on the same unit.
Plan Of Correction
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.