Failure to Protect Resident from Mental Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of seven out of 15, was admitted with multiple diagnoses including emphysema, acute respiratory failure with hypoxia, acute kidney failure, and acute on chronic diastolic heart failure. The facility's policy defined mental/emotional abuse as conduct that could cause humiliation, intimidation, fear, shame, agitation, or degradation. Despite this policy, a Certified Resident Care Aide (CRCA) directed an inappropriate hand gesture (middle finger) toward the resident in response to the resident's behaviors. The incident was reported by the resident to the nurse on duty, and the CRCA admitted to making the gesture. Witness statements and interviews with staff confirmed the CRCA's actions and acknowledgment that the gesture could be perceived as abuse. The Director of Health Services classified the gesture as mental abuse, consistent with facility policy. The deficiency centers on the failure to protect the resident from mental abuse perpetrated by a staff member.