Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
Three separate incidents involving three residents demonstrated the facility's failure to protect residents from abuse and neglect, as required by policy. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment, who was at risk for elopement, was left unattended outside the facility by a Certified Nurse Aide (CNA). The CNA brought the resident outside, assumed there was a group activity, and left the resident unsupervised for an extended period until a visitor returned the resident inside. The resident's care plan specifically required that they not be left unsupervised when outside the unit, including outside the building. In the second incident, a resident with left-sided hemiplegia and hemiparesis following a stroke, as well as chronic respiratory failure and heart failure, was injured when a CNA failed to use a mechanical lift as directed in the resident's care plan and care card. Instead, the CNA transferred the resident without assistance, resulting in the resident's foot becoming caught under the bed and sustaining a bruise. The resident reported that this CNA did not use the lift, while other aides did follow the care plan. The third incident involved a resident with hypertensive heart disease, chronic kidney disease, and type 2 diabetes, who was slightly cognitively compromised and had a history of behavioral symptoms. Two CNAs did not provide personal care in the manner preferred by the resident, leading the resident to resist care and sustain a bruise to their hand after hitting it on the side rail. The resident reported being flipped and shoved during care, and the investigation confirmed that care was not provided according to the resident's preferences, resulting in the injury.