Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident with dementia and behavioral disturbances by intentionally holding the resident’s door shut, resulting in the resident’s fingers being caught in the door and causing bleeding and lacerations. The resident, who had significant cognitive and physical impairments, was on 1:1 supervision due to behavioral issues and a history of falls. Despite these needs, the CNA was observed on video holding the door closed while the resident struggled to open it, ultimately causing injury to the resident’s hand and forearm. The CNA was seen smiling at the camera during the incident, and other staff members in the vicinity did not intervene or respond to the resident’s distress. Multiple staff, including licensed nurses and other CNAs, were present during the incident but failed to take action to prevent or stop the abuse. Video footage confirmed that the CNA continued to hold the door shut even as the resident’s fingers were caught, and other staff either ignored the situation or did not provide assistance. Witnesses, including a visitor, observed the resident bleeding and attempting to get help, but nurses at the station did not respond until prompted by the visitor. The lack of immediate intervention by staff contributed to the resident’s harm and prolonged distress. The resident sustained injuries requiring hospital evaluation, including lacerations to the right hand and left forearm, though no fractures were found. The incident was not immediately reported accurately to the resident’s responsible party, and discrepancies in staff accounts were only clarified after video review. The facility’s policies required staff to report and prevent abuse, but these were not followed, as evidenced by the failure to protect the resident from physical harm and the lack of timely and appropriate staff response.