Failure to Protect Residents from Abuse and Rough Handling by Staff
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse, as evidenced by multiple incidents involving staff members. One resident with dementia and a history of aggressive behaviors was involved in an incident where a registered nurse, after being struck by the resident, responded by grabbing the resident's hands and raising her voice, rather than deescalating the situation. Video evidence provided by the resident's family showed the nurse's actions were abrupt and not in line with best practices for managing combative behaviors. In a separate incident, a certified nurse aide providing care to the same resident was reported to have hit the resident's head on an enabler bar during care and failed to report the incident to the nurse on duty. Another resident with severe cognitive impairment and a recent hip fracture was subjected to unprofessional and rough care by an agency aide. Video footage reviewed by facility leadership showed the aide mocking the resident's expressions of pain and handling the resident roughly during incontinence care and transfers, despite the resident's vocalizations of pain. The aide was observed mimicking the resident's moaning and using forceful movements during care, while a licensed practical nurse present in the room did not intervene to stop the rough handling. The facility's own policies required that all residents be free from abuse, neglect, and exploitation, and that all alleged violations be reported to the State Survey Agency. However, the report indicates that the incident involving the agency aide was not reported as required. Additionally, staff training on sensitivity and abuse prevention was not provided until several months after the incidents occurred. These failures resulted in two residents not being protected from abuse and the facility not adhering to its own policies and regulatory requirements.