Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent incidents of both staff-to-resident and resident-to-resident abuse, affecting two residents. In one incident, a Certified Nursing Assistant (CNA) used profanity and physically handled a resident with severe cognitive impairment and dementia by placing hands on the resident's shoulders to restrict movement in a wheelchair. A family member witnessed the CNA aggressively jerking the wheelchair and using profane language toward the resident. The CNA had a documented history of prior disciplinary actions for similar behaviors, including previous use of profanity in the presence of residents and leaving residents unsupervised. In a separate incident, a resident with a history of verbal and physical aggression entered another resident's room despite being told not to by both a CNA and the resident. The aggressive resident picked up a plastic bubble wand and struck the other resident on the head and face, resulting in a significant bump, bruising, dizziness, and a high level of pain. The CNA present was unable to immediately intervene as he was providing care to another resident at the time. Both incidents demonstrate a lack of adequate supervision and failure to enforce abuse prevention policies. The facility's own documentation and staff interviews confirm that the abuse occurred and that the affected residents suffered physical and emotional harm as a result. The facility's policies prohibit such abuse, but repeated violations and insufficient supervision contributed to the deficiencies.