Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment, multiple chronic conditions, and a history of behavioral challenges was physically abused by a certified nurse aide (CNA) during care. The resident, who required substantial assistance with transfers and had a BIMS score indicating severe cognitive impairment, was observed to have two red marks on their right leg that were tender to touch. The abuse occurred when the resident became aggressive and resistant to care, leading the CNA to respond by grabbing the resident's face, twisting their head and fingers, pulling their hair, and punching the resident twice in the leg. The incident was witnessed by another CNA, who later reported the abuse to a nurse. The resident was able to recall being hit and having their hair pulled during an assessment, although they could not identify the perpetrator by name but indicated it was a male. Documentation from staff statements and progress notes confirmed the physical abuse, with the nurse and DON both assessing the resident for injuries and noting the presence of red marks and tenderness on the leg. The resident's family was notified of the incident and confirmed that the resident reported being struck by a male staff member. Staff interviews indicated that the resident had not previously complained about staff and that this was the only reported incident of abuse involving the CNA in question. The incident caused the resident to express fear of the CNA involved, and staff also reported feeling afraid of the CNA due to their actions. The facility's abuse policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The events leading to the deficiency included the CNA's reaction to the resident's aggressive behavior by inflicting physical harm, the delay in reporting the abuse by the witnessing CNA, and the subsequent identification of physical injuries consistent with the reported abuse. The facility's documentation and staff interviews confirmed that the resident was not protected from abuse as required by policy.