Failure to Prevent Physical and Mental Abuse During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) physically and mentally abused a resident with severe cognitive impairment during a transfer. The resident, who had Alzheimer's disease, depression, and was dependent on staff for all activities of daily living, was observed being rushed and handled roughly by the CNA. The CNA was seen pulling and yanking the resident's arm while attempting to transfer her from a chair to bed, without first explaining the procedure or ensuring the resident was ready. The resident became visibly upset, resisted the transfer, and displayed signs of distress, such as laughing angrily and gritting her teeth. Multiple staff members witnessed the incident. One CNA entered the room and observed the resident being pulled and yanked by the arm, and heard the CNA repeatedly and loudly urging the resident to get up. Despite being asked to leave the room by another CNA and an LPN, the CNA continued to attempt the transfer and only left after repeated requests. The resident was calmed by another CNA after the incident, and no physical injuries were noted, but the resident was clearly distressed by the interaction. The facility's care plans for the resident specified that she required maximum assistance from two staff members for transfers and that staff should allow her sufficient time to complete tasks without rushing. The CNA failed to follow these care plan interventions, instead rushing the resident and using rough handling during the transfer. The incident was reported by staff, and interviews confirmed that the CNA's approach was inappropriate and did not align with the resident's care needs or the facility's abuse prevention policies.