Failure to Protect Resident from Verbal and Physical Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, dementia, anxiety disorder, legal blindness, and cerebrovascular disease was subjected to verbal and physical abuse by a nurse aide in training during care. The resident was fully dependent on staff for emotional, intellectual, physical, and social needs, and had a self-care deficit related to activities of daily living. The abuse included the aide striking the resident on the mouth, telling him to hush, covering his mouth with her hand, aggressively placing him in a sit-to-stand machine, and instructing him to urinate in his brief. These actions were witnessed by another certified nursing assistant, who provided both a written statement and an audio recording of the incident. The audio recording captured the aide yelling at the resident to hush and shut up, mocking him, making threatening statements, and giving harsh instructions. The aide admitted to telling the resident to hush and to playfully tapping him, but denied hitting him. Documentation also indicated that the resident expressed fear of a staff member, though he was unable to recall the specific incident during a later interview. The resident's trauma-informed assessment revealed a history of childhood trauma, ongoing feelings of fear and helplessness, and a tendency to try to forget past traumatic events. The incident was reported to facility leadership, and the aide's timecards confirmed her presence during the dates in question. The facility's documentation included witness statements, progress notes, and the audio recording, all substantiating the occurrence of abuse. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from abuse, resulting in likely emotional distress and trauma.
Removal Plan
- R #4 was assessed by using a Trauma Informed Assessment. No immediate concerns noted.
- Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.
- Safe survey for all facility residents were initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe.
- Referral for additional spiritual services for support within the community for R #4 via hospice team.
- R #4's Care Plan updated for trauma-informed care.
- All staff were re-educated on: Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report; Zero-tolerance expectation; Resident rights; Mandatory reporting within 2 hours.
- Staff training was conducted for all facility staff.