Failure to Protect Residents from Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect multiple residents from abuse, as evidenced by physical, verbal, and psychological harm caused by a CNA. One resident, who was severely cognitively impaired and dependent on staff for all care, was physically injured when the CNA grabbed their arms, resulting in fingerprint bruises and a nail-inflicted skin tear. This resident subsequently exhibited significant mood changes, including frequent crying, increased distress behaviors, multiple days of refused care and medications, and repeated verbalizations of fear of being physically hurt. Documentation showed that the injuries and behavioral changes were not promptly assessed, reported, or investigated by nursing or management staff, despite being observed and reported by other CNAs. Other residents, most of whom were cognitively intact but physically dependent, reported or were observed to experience rough, hurried, or intimidating care from the same CNA. Several residents described being treated roughly during transfers or personal care, being spoken to in a demeaning or intimidating manner, and feeling fearful or anxious about receiving care from the CNA. Some residents reported changes in their behavior, such as avoiding common areas or losing sleep, to avoid interactions with the CNA. Despite these reports and observations, the CNA continued to provide care to residents for an extended period after the initial incident. The facility's policies required immediate reporting, investigation, and protection of residents from abuse, but these procedures were not followed. The responsible nurse manager did not suspend the CNA, did not initiate an investigation, and did not report the suspected abuse to facility leadership or the state agency as required. Injuries and behavioral changes were not documented or monitored in a timely manner, and residents were not protected from further potential abuse during the period in question.