Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) was physically rough and abusive while providing incontinence care to a resident with multiple diagnoses, including Alzheimer's Disease, osteoarthritis, anxiety disorder, and depression. The resident was not cognitively intact and exhibited distress during care, such as clenching teeth, grimacing, moaning, crying, covering her face, and attempting to take a defensive position. The CNA pressed and held the resident's hand down on her chest, adjusted her legs roughly, and wiped her perineal area forcefully, causing visible discomfort and pain. The CNA also pulled on the resident's incontinence brief with enough force to cause the resident's body to jerk upwards in bed. Further observations showed the CNA continued to be rough during care, including pulling the resident's shirt off firmly and tying a gown without lifting the resident's head, which caused additional distress and grimacing. Another CNA present during the incident reported that the abusive behavior was not isolated to this resident but was a pattern with other residents as well. The witness described the CNA as harsh, rough, overly aggressive, and unkind, and stated that the resident became combative as a result of the harsh treatment. The witness did not report the abuse immediately, citing concerns about being an agency staff member and fear that her word would not be believed over the CNA's. The facility's abuse policy defines abuse as any action causing physical harm, pain, or mental anguish, including physical and mental abuse. The incident was captured on video and confirmed by the Director of Nursing, who acknowledged the abusive behavior. The failure to protect the resident from abuse and mistreatment resulted in the identification of Immediate Jeopardy, as the resident was subjected to physical and emotional harm during routine care.
Removal Plan
- V3's employment with the facility was terminated.
- V2/DON and V15/Risk Manager performed a visual assessment of resident (R1) for signs of physical and emotional abuse; no physical marks noted and patient's emotional status unchanged.
- V1/Chief Nursing Officer, V2, and V15 reviewed LTC/Long Term Care Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.
- V2 reviewed the LTC Abuse and Neglect Procedures Policy and Behavior Standards with the V18/Assistant Director of Nursing and then all staff on shift was educated.
- Staff not working day shift were called by V18 and V2 and the LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, were reviewed.
- Remainder of staff not working or reached by phone will be required to receive education on LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, prior to working next shift by the V2 or V18 and will be tracked on sign-in sheet.
- Long Term Care Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift.
- An Emergency QAPI/Quality Assurance Performance Improvement discussion was held with V1/Chief Nursing Officer, V2, V17/Social Services Director, V20/Medical Director, and V15 to review the resident audit findings performed and review investigation.
- On-going audit plan was created: Five residents a month will be interviewed by Social Services or V2 or designee about cares received and any concerns regarding cares. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality Assurance meetings.