Failure to Protect Resident from Verbal and Mental Abuse by Staff
Penalty
Summary
Resident #300, who had chronic peripheral venous insufficiency, a nonthermal blister on the right lower leg, moderate cognitive impairment, and required substantial assistance for toileting and hygiene, was admitted to the facility. The resident was dependent on staff for care and was occasionally incontinent of urine and frequently incontinent of bowel. On the evening in question, the resident reported that after using the call light for toileting assistance, a CNA told them to learn to use the urinal or their diaper, and then refused to help. The resident stated they did not receive help for several hours and, when requesting clean linens, was again refused assistance and told to learn how to change the linens themselves. The resident also reported that when asking for help with a phone charger, the CNA refused and acted aggressively in the room. These incidents were overheard by a family member on the phone, who later reported the behavior to facility staff and administration. A review of the facility's abuse investigation file confirmed that an initial report of verbal abuse was submitted to the State Department of Public Health, naming the CNA as the alleged perpetrator. The investigation included statements from the resident, the family member, and the involved CNA, who denied the allegations. Another CNA present during care also denied hearing any rude or mean comments. However, a registered nurse assigned to the resident that night described the CNAs' behavior as cruel and bordering on mental abuse, noting that the resident became agitated and anxious when the CNAs would not respond to their repeated questions about their identities. The nurse reported this incident to the Director of Nursing, though the timing of the report was unclear. The family member corroborated the resident's account, stating they overheard the CNA telling the resident to toilet themselves and to void in their brief if unable to use the toilet independently. The family member also reported that one CNA sat in a chair while the other changed the resident's clothing in front of them, and that the resident was left without assistance for an extended period. The family member reported the incident to facility staff on the night it occurred and later to the administrator. The administrator and Director of Nursing stated they were unaware of the potential mental abuse reported by the nurse. The facility's investigation ultimately determined there was no evidence to substantiate the alleged abuse.