Failure to Protect Resident from Physical Abuse and Staff Inaction
Penalty
Summary
A certified nursing assistant (CNA) responded to multiple falls of a resident with severe cognitive impairment by using physical force and restraint, without notifying a nurse or requesting assistance. The CNA lifted the resident from the floor alone, despite the resident resisting, and placed him roughly into his wheelchair. The CNA also locked the wheelchair brakes, preventing the resident from moving, and did not seek a nurse's assessment after the falls. Video footage confirmed these actions, and the resident was observed to have bruises on his arms corresponding to where the CNA had grabbed him. The resident displayed increased anxiety during interactions with the CNA. Eight additional staff members, including other CNAs, a licensed practical nurse (LPN), certified medication assistants (CMAs), and food service staff, were present during these incidents but did not intervene or report the abuse to a supervisor at the time. The LPN did not assess the resident after the falls, and staff did not assist the resident or stop the CNA from using rough handling. The resident was left on the floor for an extended period after one fall, and staff failed to follow protocols for post-fall assessment and safe transfer. Review of training records revealed that several staff members, including contracted travel staff and long-term employees, had not received required abuse and neglect training. Documentation of abuse and neglect training was missing for multiple staff, and recent staff meetings and training sessions did not include education on abuse or neglect. The facility's policy required all staff to report suspected abuse or neglect, but this was not followed during the incidents described.