Failure to Prevent Abuse and Honor Resident Refusals During Showering
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically for two residents with severe cognitive impairment and mental health diagnoses. One resident, who had a history of trauma, chronic pain, COPD, Alzheimer's disease, and anxiety disorder, was physically lifted from her bed by a CNA under her armpits and given a shower despite her repeated verbal refusals. The resident expressed anger and mental anguish as a result of being forced to shower against her will. Documentation and interviews confirmed that the resident was able to communicate her wishes and had the capacity to make informed decisions at the time of the incident. Another resident, who was the roommate of the first, also experienced mental anguish after overhearing the incident. This resident, who had diagnoses including cancer, heart failure, stroke with paralysis, and major depressive disorder, reported being upset by hearing her roommate being forced to shower by staff. Both residents were on mental health services, and their care plans included interventions for cognitive impairment and trauma-informed care, including respecting refusals and stopping care if the resident became escalated. Staff interviews and record reviews revealed that the CNAs involved were aware of the residents' right to refuse care but proceeded with the shower regardless. The incident was reported by the affected resident to nursing staff and was corroborated by her roommate and other staff members. The event was documented in progress notes, care plans, and verbal statements, and was identified as Immediate Jeopardy Past Noncompliance by surveyors. The actions of the staff directly contradicted the residents' expressed wishes and established care plan interventions, resulting in documented mental distress for both residents.