Forcible Handling of Resident with Dementia Results in Substantiated Abuse
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, depression, and hypertension, who was rarely or never understood and had a care plan indicating a need for personal space and minimal physical contact, was forcibly moved down a hallway against her will by a certified nurse aide (CNA). The resident was exhibiting combative behaviors and was near a door at the end of the hallway when a registered nurse (RN) attempted to redirect her. The CNA intervened by hooking her arm under the resident's arm and physically moving her, despite the resident's resistance and vocal objections. Multiple staff interviews confirmed that the CNA was visibly angry and used inappropriate language during the incident, stating, "we aint doing this sh*t today," before forcibly moving the resident. Other staff, including an LPN and another CNA, witnessed the event and expressed discomfort with the CNA's actions, describing the resident as being dragged while fighting and yelling. The resident was described as acting scared and traumatized following the incident, and staff noted that she followed another CNA around for the rest of the night. The facility's initial abuse investigation deemed the allegation unfounded, but after further staff interviews and review, the incident was substantiated as abuse. The facility's policy prohibits abuse, including the willful infliction of injury or unreasonable confinement, and requires interventions that respect residents' needs and behaviors. The failure to follow the resident's care plan and the use of force resulted in psychosocial harm, as evidenced by the resident's subsequent behavior and staff observations.
Removal Plan
- Administrator, Director of Nursing, and Assistant Director of Nursing reviewed Abuse Policy and intervening and reporting with quiz; Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout with all on duty staff in person. All staff not working at the time were reached by phone and were educated. Any staff who were not reachable will not be able to clock in for their next shift until DON or ADON provide the education and handouts.
- The Abuse policy and intervening and reporting with quiz, Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout specific to intervention of preventing abuse and recognizing stress and burnout in co-workers and intervening was added to the orientation packet for new staff.
- An emergency QAPI (Quality Assurance and Performance Improvement) discussion was held with the Medical Director, Administrator, DON, ADON, and Social Service Director to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit will be conducted of 5 residents and 5 staff per month by DON, ADON, Social Services Director and/or designees about Abuse, Stress, and Burnout and concerns regarding any cares. These audit tools will be reported monthly on the QAPI scorecard and reported at the QA meeting.
- All residents with Alzheimer's Disease/Dementia were reviewed for At Risk for Abuse/Harm and any identified, care plan was added and/or updated by Social Services Director.
- Administrator and Director of Nursing will meet monthly to review all audit findings for discussion for need, if any, for further training/education and/or policy review changes.