Failure to Protect Residents from Physical and Verbal Abuse
Penalty
Summary
Three residents were not protected from physical and verbal abuse as required by facility policy. In one instance, a resident receiving care from an agency CNA was treated roughly, with the CNA pulling the resident's legs apart and being rough while cleaning, despite the resident voicing pain and asking the CNA to stop. Another CNA was present during this incident but did not intervene to stop the rough treatment, only reporting the concern after the care was completed. The facility's Social Services Director and Nursing Home Administrator confirmed that the witnessing CNA was expected to intervene immediately to protect the resident but did not do so. In two separate cases, a registered nurse was alleged to have physically and verbally abused two residents with significant cognitive and physical impairments. One resident, who had severe dementia and was dependent for care, was rolled and wiped aggressively, causing distress and pain, while the nurse made inappropriate verbal remarks. The incident was witnessed by a CNA, who reported it to another nurse. However, instead of immediately escalating the report to facility leadership, the CNA and nurse left written statements under the DON's office door, who was not present at the time. This delayed the initiation of an investigation and allowed the accused nurse to continue working subsequent shifts before the allegations were addressed. The second resident, who also had significant neurological and physical impairments, was similarly treated aggressively by the same nurse. The CNA's statement described the nurse rolling the resident onto their affected side and wiping them aggressively, causing visible pain. Again, the report was not immediately brought to the attention of facility leadership, and the nurse continued to work. In both cases, the facility failed to ensure immediate protection of the residents from further potential abuse, as required by their own policies.