Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
A resident with amyotrophic lateral sclerosis (ALS), dysphagia, and facial weakness experienced verbal and physical abuse by two Certified Nursing Aides (CNAs) during care. The CNAs pulled on the resident's arms despite the resident expressing discomfort and shaking his head no. The resident's communication device was moved out of reach, preventing him from communicating his needs. The resident's minor family member, who was present, had to intervene and tell the CNAs to stop pulling on the resident's arms due to pain. The CNAs also changed the resident's brief in front of the minor family member and attempted to put the resident to bed earlier than desired, using a mechanical lift when the resident was able to stand and shuffle. The resident was left in his shirt for bedtime after expressing distress. During the incident, one CNA suggested rolling the resident onto his side and dropping him to make it look like an accident. The resident was unable to lie flat in bed, but the CNAs attempted to position him that way, causing further distress. The resident became upset and wanted to call 911. Interviews with staff and the hospice case manager indicated the CNAs were unfamiliar with ALS care, and the situation escalated until the resident's adult family member intervened. The incident was self-reported by the facility, and the CNAs involved were not assigned to care for the resident following the event.