Failure to Protect Resident from Staff Abuse During Transfers
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, morbid obesity, major depression, and reduced mobility, was not protected from abuse by staff. The resident, who was dependent on staff for most activities of daily living and had fragile skin, experienced several incidents involving a CNA. During one transfer, the CNA caused a skin tear on the resident's arm while assisting her into a sitting position. The injury was documented, and the resident denied pain at the time, but the incident was not reported as abuse. Further review and interviews revealed additional concerning events. Another CNA reported that the same CNA dropped the resident from a hoyer lift into a shower chair from a significant height and later violently yanked the hoyer pad, causing the resident's head to snap back. The resident expressed fear of this CNA and reported that her hair had been pulled during care, though she was unsure if it was intentional. The resident and her family requested that this CNA no longer provide care due to perceived roughness and an uncaring attitude. Another family made a similar request for a different resident. Despite these reports and concerns, the facility did not have a policy or procedure for hoyer lift use, and the Director of Nursing and Administrator did not report the incidents as abuse. The lack of reporting and absence of a clear policy contributed to the failure to protect the resident from potential abuse and neglect by staff.