Failure to Protect Resident from Verbal Abuse and Aggressive Handling
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple comorbidities, including dementia, mood disorder, and physical weakness, was subjected to verbal abuse and aggressive handling by a CNA during incontinence care. A Personal Care Attendant (PCA) witnessed the CNA using explicit language, threatening to let the resident fall, and aggressively transferring the resident to a wheelchair, after which the resident was observed shaking. The PCA reported the incident to the Director of Nursing (DON), who instructed the PCA to continue training with another CNA. The PCA also reported feeling retaliated against for reporting the abuse, including being told to limit details in her written statement and experiencing a hostile work environment, with the CNA making threatening remarks such as 'snitches get stitches.' The facility conducted an internal investigation, but the DON and Nursing Home Administrator (NHA) determined the allegation was inconclusive, citing the resident's inability to communicate due to severe cognitive impairment. The resident was not evaluated by psychiatric services until several days after the incident, due to the psychiatric provider's unavailability. The psychiatric and social work assessments found the resident confused and unable to recall the incident, with no immediate signs of distress observed. The CNA involved was suspended and later returned to work before being suspended again for making threatening remarks in the parking lot. Interviews with other staff confirmed awareness of the incident and that abuse and neglect training had been provided. The facility's policy prohibits all forms of abuse and outlines procedures for prevention and reporting. Despite these policies, the incident involving verbal abuse and aggressive handling was substantiated by direct witness testimony and staff interviews, indicating a failure to protect the resident from abuse as required.