Failure to Protect Residents from Physical Abuse During Transfers
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when a Certified Nurse Aide (CNA) forcefully transferred them from their beds to their wheelchairs. Multiple staff members, including two CNAs and an LPN, witnessed the CNA acting in an angry and agitated manner, roughly grabbing the residents under their arms and moving them without the use of a gait belt. The transfers were performed quickly and forcefully, causing visible distress and fear in the residents. The CNA did not communicate with the residents during the transfers and did not follow proper transfer protocols as outlined in the residents' care plans. Both residents involved were assessed as cognitively impaired and required extensive assistance with activities of daily living, including transfers. Their care plans specifically required the use of two staff members and a mechanical lift or extensive assistance for transfers, as well as the use of gentleness and clear communication to reduce anxiety and pain. Despite these requirements, the CNA transferred the residents alone, without a gait belt, and in a manner that caused one resident to complain of arm pain and the other to require pain medication for moaning. Staff documentation and resident interviews confirmed that the transfers were performed in a rough and unsafe manner, resulting in physical and psychological distress. The incident was reported by staff who were visibly upset by what they witnessed. The residents' medical histories included dementia, anxiety, depression, osteoarthritis, and osteoporosis, making them particularly vulnerable to injury and distress from improper handling. The facility's own investigation and staff statements corroborated that the CNA's actions violated established safety protocols and resident rights, directly leading to the deficiency.