Failure to Prevent Verbal, Mental, and Physical Abuse During Incontinence Care
Penalty
Summary
The facility failed to protect residents from verbal, mental, and physical abuse, as evidenced by the actions of a Certified Nurse Aide (CNA) toward two residents during incontinence care. One resident, who was cognitively intact and dependent for toileting hygiene, reported that the CNA struck his legs and scolded him after discovering his condom catheter had come off and his brief was wet. The resident experienced involuntary muscle spasms during care, and the CNA responded by hitting him and telling him to stop tensing up. The resident was left feeling afraid, humiliated, and unable to defend himself, resulting in emotional distress and a desire to leave the facility. Another resident, who had moderate cognitive impairment and was also dependent for toileting hygiene, reported that the same CNA scolded and berated him for being incontinent, making him feel ashamed, humiliated, and fearful that the behavior would recur. The CNA admitted to being frustrated and 'fussing' at the resident, telling him to stop urinating in bed after having to change his bed and clothes multiple times during the shift. The resident did not respond to the CNA but reported feeling intimidated and afraid. Interviews and record reviews confirmed that both residents experienced emotional distress as a result of the CNA's actions. Staff interviews corroborated the residents' accounts, with one staff member finding a resident crying and reporting the incident to nursing leadership. The facility's own policy prohibits abuse, including intimidation and the infliction of mental anguish, yet the CNA's conduct during care directly violated these standards, resulting in significant emotional harm to the residents involved.