Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, including verbal and physical abuse, as evidenced by direct observations, interviews, and record reviews. One resident with severe cognitive impairment, expressive aphasia, and total dependence on staff for care was subjected to verbal abuse by a contract CNA, who used profane language and derogatory remarks while the resident was hollering out. Witnesses, including a medication aide and a PASRR provider, confirmed hearing the CNA use inappropriate language directed at or about the resident. The resident was unable to communicate effectively due to her condition, and her care plan emphasized the need for staff to use clear, simple instructions and alternative communication methods. Another resident with moderate cognitive impairment, dementia, and a history of making racial slurs towards staff alleged that a medication aide used a racial slur against her. The resident reported feeling insulted by the comment. The medication aide admitted to responding to the resident's use of a racial slur by asking how the resident would feel if called "white trash." The aide acknowledged the exchange and stated that it was prompted by the resident's offensive language. The facility's investigation included interviews with the resident, the accused staff member, and witnesses, but the incident was ultimately deemed unfounded by the former administrator. A third resident with severe cognitive impairment, mobility deficits, and a history of falls was allegedly subjected to physical abuse during a brief change. Family members reported hearing the resident scream in pain and observed, via partially obstructed camera footage, a CNA pulling a chuck from under the resident in a manner they believed was rough. The resident, due to memory loss, could not recall the incident. The CNA involved stated she was attempting to prevent the spread of feces and denied mistreatment. The facility's maintenance and equipment practices were also discussed, as bed movement was a concern during care. These incidents demonstrate failures in ensuring residents' rights to be free from all forms of abuse.