Failure to Protect Residents from Abuse and Ensure Staff Training
Penalty
Summary
Two residents experienced abuse and mistreatment by a certified nurse assistant (CNA) during the provision of care. One resident, a seventy-one-year-old with hemiplegia, hemiparesis, dysphagia, vascular dementia, and major depression, required maximum assistance with activities of daily living (ADLs) and was dependent for transfers and mobility. During care, the resident reported that the CNA was rough, causing pain, and despite requests to stop, the CNA continued. The resident then pulled the CNA's hair in an attempt to make her stop, after which the CNA punched the resident in the mouth. This resulted in the resident sustaining a swollen, discolored lip and jaw, with ongoing pain. Multiple staff and family members observed the injuries, and the resident consistently reported the incident to staff, family, and the nurse practitioner. The CNA did not report the incident and denied hitting the resident when questioned. Another resident, a seventy-year-old with hemiplegia, hemiparesis, dysphagia, COPD, and reduced mobility, reported that the same CNA was repeatedly rough during care, verbally rude, and removed the resident's food tray before meals could be eaten. The resident described the CNA as cruel and disrespectful, causing increased pain and mental anguish. The resident reported these incidents to the administrator, stating that the CNA's actions made him feel bad about himself and less than a man. The administrator did not recall being told about these concerns prior to the surveyor's interview. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment. However, the CNA involved in both cases stated she had not received abuse training and was unaware of the abuse coordinator. The incidents were substantiated based on resident reports, observed injuries, and staff interviews, indicating a failure to protect residents from abuse and to ensure staff were adequately trained and aware of abuse prevention protocols.