Failure to Protect Resident from Abuse and Neglect by Staff
Penalty
Summary
A deficiency occurred when a resident with dementia and intact cognition, who was independent with eating and able to use the call light for toileting assistance, was subjected to neglect and abuse by facility staff. The resident was found yelling and lying beside her bed after a fall, with no immediate documentation or assessment of the incident. A CNA reported that another CNA placed an incontinence product on the resident, despite her ability to request toileting assistance, to avoid frequent toileting. The same CNA informed the resident she would be checked and changed later, disregarding the resident's actual needs and preferences. Following the fall, the LPN instructed two CNAs to assist the resident back to bed without performing an assessment or taking vital signs. During the transfer, when the resident began to yell, the LPN placed her hand over the resident's mouth and asked her to be quiet. The CNA who witnessed these actions delayed reporting the incident due to previous negative experiences with reporting at another facility and fear of retribution. The incident only came to management's attention when the CNA later explained her reasons for not wanting to continue working at the facility. The facility's investigation confirmed that the LPN and CNA involved in the incident admitted to the actions described, including failing to assess the resident after a fall, placing an incontinence product on the resident unnecessarily, and attempting to silence the resident by placing a hand over her mouth. These actions were in direct violation of the facility's abuse and neglect policy, which requires prompt reporting and protection of residents' rights and well-being.