Failure to Protect Resident from Staff-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia and chronic kidney disease, was found with bruising under the left eye and on the left wrist. The resident reported being hit in the eye, but could not provide further details. Nursing staff documented the injuries and conducted assessments, noting the new bruises and monitoring the resident's condition. The incident was further corroborated by a nurse who observed the bruising and by another nurse who completed follow-up skin assessments. A Certified Nursing Assistant (CNA) who was new to healthcare and in orientation reported that while assisting with care, another CNA was aggressive during a transfer, grabbing the resident's wrists and throwing the resident onto the bed. The resident was noted to have said "ow" during the interaction. Although neither the reporting CNA nor the resident's roommate witnessed the resident being struck in the face, both described the care as rough and aggressive. The resident was described as combative and agitated during the incident. The facility's investigation, which included review of witness statements and personnel records, determined that the CNA involved had engaged in behavior that violated facility work rules, including physical mistreatment and actions that placed the resident at risk of harm. The incident resulted in physical bruising and was reported by both the resident and witnesses. The CNA was subsequently terminated for violent behavior and use of force towards residents, as documented in the personnel file and corrective action form.