Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by two certified nurse aides (CNAs). The resident, who was cognitively intact but had significant physical and communication impairments due to multiple neurodegenerative conditions, required extensive assistance with transfers and toileting. According to interviews and video evidence provided by the resident's representative, the CNAs handled the resident roughly during care, including pulling on his arms, using an aggressive tone, and yanking his t-shirt to force him into a wheelchair. The resident reported feeling disrespected and that staff lacked compassion, often speaking to him aggressively and not allowing adequate time for him to respond due to his communication deficits. The resident's care plans specifically outlined the need for staff to allow adequate time for responses, avoid rushing, and use clear, patient communication methods due to his hearing and speech difficulties. Despite these interventions, the CNAs did not follow the care plan, instead providing care in a hurried and forceful manner. The video evidence also showed that care was provided with the door open and no privacy curtain, further compromising the resident's dignity. Staff interviews indicated that the expectation was to treat residents with respect and dignity, and that staff had received education on these topics. However, the actions of the two CNAs during the incident did not align with these expectations or the facility's abuse prevention policy, which prohibits verbal, mental, or physical abuse by anyone, including staff. The facility substantiated the allegation of physical abuse based on the evidence provided.