Failure to Prevent and Address Staff Abuse of Resident with Severe Cognitive Impairment
Penalty
Summary
A staff member failed to protect a resident with severe cognitive impairment from abuse. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression, was dependent on staff for toileting hygiene and required assistance for toilet transfers. The incident involved a certified nursing assistant (CNA) who recorded and posted a video on social media from the resident's bathroom. In the video, the resident could be heard asking to be let out, while the CNA repeatedly referenced the resident's incontinence in a demeaning manner. The CNA later confirmed the details of the incident and did not recognize the wrongdoing. The facility's investigation revealed that the incident was not reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, despite policy requirements for such cases to be analyzed for root causes and systemic risk factors. The policy also identified demeaning or humiliating videos of residents as possible indicators of abuse, regardless of consent or cognitive status. The Director of Nursing confirmed that, aside from staff education and monitoring the resident, no further action was taken to ensure prevention of similar incidents, and the required QAPI review did not occur.