Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A cognitively impaired resident residing in a secured memory care unit, who was dependent on staff for activities of daily living and known to be resistive to care, was subjected to verbal and physical abuse by a certified nursing assistant (CNA). The CNA became frustrated while assisting the resident with undressing, aggressively removed the resident's arm from his sweatshirt, and attempted to pry the shirt from his hands, causing the resident to verbally express pain. The incident was witnessed by another staff member, who reported discomfort with the CNA's actions and observed a change in the CNA's demeanor upon realizing she was being watched. The resident had severe cognitive impairment and was unable to be interviewed about the incident. In a separate incident, another cognitively impaired resident who required total staff assistance for toileting and repositioning was left on a bedpan for an extended period of time by a CNA. The resident was unable to reposition herself and was found with linear, slow-to-blanch marks on her buttock, consistent with prolonged pressure from a bedpan. Documentation and staff interviews confirmed that the resident had been placed on the bedpan during the night shift and was not removed until discovered by day shift staff several hours later. The resident's care plan required frequent repositioning and total assistance with toileting, which was not provided as required. Both incidents involved residents with significant cognitive impairment and dependency on staff for care. In the first case, the resident's care plan included specific interventions for resistance to care, such as reassurance and re-approaching after a short interval, which were not followed. In the second case, the failure to remove the resident from the bedpan in a timely manner resulted in a skin injury. The events were substantiated through staff interviews, record reviews, and direct observation, demonstrating failures to protect residents from abuse and neglect.