Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
A certified nursing assistant (CNA) failed to protect a resident from potential physical abuse during morning care. The resident, who was cognitively intact and had a history of Parkinson's disease, hypertension, spinal stenosis, and falls, reported to multiple staff members that the CNA was upset with him and handled him roughly. The resident sustained an ankle injury and abrasions on both shins during the transfer from bed to wheelchair, and required both scheduled and PRN pain medication for his ankle pain. Staff observed the resident's distress and documented new skin injuries following the incident. In a separate incident, a resident with moderate cognitive impairment and a history of traumatic brain injury, dementia, and psychiatric conditions made unsolicited sexual advances toward another resident. The event was witnessed by a registered nurse, who observed the resident placing his hand inside the shirt of a female resident. Video footage confirmed the inappropriate contact, which lasted approximately twenty seconds before staff intervened. The resident's medication review revealed that his scheduled Depo-Provera injections, intended to help control sexually inappropriate behaviors, had not been administered for two consecutive months due to medication unavailability and scheduling issues. Both incidents involved failures to protect residents from abuse—physical in the first case and sexual in the second. In each case, the deficiencies were identified through resident reports, staff observations, and review of medical and facility records. The events highlighted lapses in staff conduct and medication administration that directly led to residents being exposed to abuse or potential abuse.