Resident Left Unattended in Mechanical Lift and Subjected to Verbal Abuse
Penalty
Summary
A resident with schizoaffective disorder, movement disorder, and dementia was left unattended in a mechanical lift for approximately one hour after a CNA became frustrated during a transfer. The resident required dependent assistance with two staff for transfers, as documented in the care plan. The incident was reported to the State Survey Agency, and interviews with staff and the resident's roommate confirmed that the resident was left alone in the lift, causing distress. The CNA involved refused to participate in the investigation and resigned immediately after the incident. There was no documentation of the incident in the resident's medical record, and the facility's investigation did not substantiate the event as abuse or neglect, with the rationale for this decision not fully documented. In a separate incident, the same resident requested toileting assistance and a CNA raised her voice, stating she was only required to provide assistance every two hours and told the resident she was not a child. Another CNA witnessed this event. There was no documentation of this verbal altercation in the resident's medical record. The facility reported the incident to the State Survey Agency, but the investigation did not verify the allegation of verbal abuse, and the reasoning for this decision was not fully documented. Interviews with staff, including the CNA coordinator and DON, confirmed that facility policy required two staff members for mechanical lift transfers and that residents should not be left unattended in lifts. The facility's policy defined abuse and neglect, including verbal and mental abuse, and required staff to recognize and prevent such incidents. Despite these policies, the incidents involving the resident were not substantiated as abuse or neglect in the facility's investigations, and documentation was incomplete.