Failure to Protect Resident from Abuse and Neglect During Fall Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to protect a resident with Huntington's disease from abuse and neglect. The resident, who had a history of falls, impaired mobility, and behavioral symptoms related to Huntington's disease, requested assistance to retrieve paper from the floor. The CNA, while sweeping the resident's room, refused to assist and instead grabbed the resident's left hand/arm, pushing the resident back, which caused the resident to fall onto the footboard of the bed and then slide off onto the floor. The CNA did not attempt to prevent the fall or assist the resident after the incident, nor did the CNA call for a nurse to assess the resident. The resident sustained a large bruise to the right buttock area and reported pain, but the facility did not assess the resident after the fall until ten days later, when the surveyor brought the resident's complaint of pain to the facility's attention. Video footage confirmed the CNA's actions and lack of intervention, and interviews with the resident and family corroborated the events. The resident expressed frustration with the CNA's behavior and stated that the CNA was not nice and did not want the CNA in the room again. Facility policies reviewed indicated a clear expectation that residents be free from abuse, neglect, and exploitation, and that staff are to provide necessary assistance and report any allegations or suspicions of abuse immediately. Despite these policies, the CNA's actions and the facility's failure to promptly assess the resident after the fall constituted neglect and a violation of the resident's right to be free from abuse and neglect.