Resident Subjected to Physical and Verbal Abuse During Medication Retrieval
Penalty
Summary
A newly admitted resident, who was unfamiliar with the facility and staff and had difficulty adjusting to the admission, was subjected to both verbal and physical abuse by the Director of Nurses (DON) and a Certified Nurse Aide (CNA). The incident occurred when the resident, who had arrived with a bag of medications and was agitated due to the unexpected nature of the admission, was observed taking pain medication from a bottle in his possession. When approached by staff, the resident refused to relinquish the medication, leading to an escalation of the situation. The DON, with the assistance of the CNA, physically restrained the resident by pinning him against the wall, blocking his exit, holding his arms, prying open his hand, and searching his pockets. Multiple staff interviews confirmed that the resident was held against the wall in an alcove across from the nurses' station, was visibly upset, and repeatedly resisted the staff's actions. The altercation was described as loud and chaotic, with both the DON and the resident yelling, and lasted several minutes. The actions taken by the DON and CNA were in direct violation of the facility's abuse prevention policy, which prohibits unreasonable confinement and abuse of any kind. The resident involved had a medical history that included alcohol dependence with alcohol-induced persisting amnesic disorder, opioid abuse, major depressive disorder, and post-traumatic stress disorder. At the time of the incident, the resident was alert, oriented, and able to make his needs known, though his Health Care Proxy was activated prior to admission. The report notes that, based on the reasonable person concept, the resident would likely have experienced psychosocial harm, fear, anxiety, or anger as a result of being restrained and searched by staff entrusted with his care.