Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
Two residents were not protected from abuse, resulting in significant deficiencies. In the first incident, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and Parkinsonism, was involuntarily secluded in their room by a Certified Nurse Aide (CNA). The CNA placed washcloth wipes in the door frame, preventing the resident from exiting for approximately three hours. The resident was later found by housekeeping staff in an unsanitary state, unclothed, with urine and feces present in the room. The CNA responsible did not alert anyone to the resident's condition or their actions, and the incident was not immediately reported to facility administration. In the second incident, another resident with moderate cognitive impairment and a history of dementia was video recorded by facility staff while washing their incontinence brief in their room. The video was posted on a social media platform by one of the CNAs involved. Multiple staff members were present during the recording, but the incident was not reported to administration in a timely manner. The video was later discovered by other staff members outside of work, who then reported it to the administration. The facility's abuse policy specifically prohibits such recordings and the use of social media in a manner that demeans or humiliates residents. In both cases, there was no documented evidence that the affected residents were assessed by a Registered Nurse, Physician, or Nurse Practitioner following the incidents. Additionally, the incidents were not reported to local law enforcement as required. The facility's policies on abuse and mental abuse related to unauthorized recordings were not followed, and staff failed to protect residents from abuse, neglect, and mistreatment as outlined in their care plans.