Failure to Protect Resident from Staff Abuse
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease and a history of stroke, was subjected to physical and verbal abuse by a Certified Nurse Aide (CNA) during post-fall assistance. The resident, who was non-ambulatory and required staff assistance for activities of daily living, was found on the floor after a fall. During the process of returning the resident to bed, CNA C was observed by two other CNAs to have kicked the resident multiple times, slapped the resident on the buttocks, and used derogatory language, calling the resident 'disgusting' in a loud and angry voice. The resident's disposable brief had fallen off, leaving him exposed during the incident, and he appeared startled, afraid, and in distress according to witness accounts. Despite witnessing the abuse, the initial response from staff was inadequate. CNA A reported discomfort with CNA C's actions to the supervising RN, but did not explicitly state that abuse had occurred, as she believed it was not her role to determine abuse but to report concerns. The RN did not immediately intervene, interview the involved staff, or remove CNA C from resident care duties. Instead, the RN delayed entering the resident's room and only reported the concern to the Nursing Home Administrator (NHA) after assessing the resident, without taking immediate protective measures or suspending the alleged abuser. The NHA was not made fully aware of the extent of the abuse until later in the day, after which CNA C was suspended and an investigation was initiated. Prior to this, CNA C continued to have access to residents. The facility's abuse prevention protocol, which requires prompt protection of residents and immediate reporting and investigation of abuse allegations, was not followed by the staff involved. The failure to act promptly and decisively resulted in psychosocial harm to the resident, including feelings of humiliation and fear, as substantiated by the facility's investigation.