Failure to Protect Residents from Physical and Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by a Certified Nursing Assistant (CNA 2). CNA 2 was observed and reported to have handled one resident with excessive force during personal care, including roughly turning, slapping, and holding down the resident's hands and arms. This resulted in a skin tear and a bruise on the resident's left forearm. The resident, who had severe cognitive impairment due to Alzheimer's dementia and was dependent on staff for toileting and incontinent care, began to yell and scream at CNA 2 whenever she was present, a behavior not previously exhibited with other staff. Documentation and interviews confirmed that the injury occurred during care provided by CNA 2, and that the resident's behavioral change was specific to interactions with this CNA. Another resident, also with Alzheimer's dementia and moderate cognitive impairment, was subjected to verbal abuse and inappropriate physical actions by CNA 2. During care, CNA 2 intentionally placed a pillow over the resident's face and told her to "shut up" while she was yelling. The resident, who was unable to remove the pillow herself due to significant physical limitations, was also subjected to CNA 2 throwing blankets over her face. CNA 1, who witnessed these actions, reported that CNA 2 frequently used harsh language and rough handling with this resident and others, particularly when frustrated by their behaviors. The facility's policy required an abuse-free environment and prompt reporting of suspected or known abuse. However, the initial report of the incidents was delayed, as CNA 1 did not immediately report the abuse out of fear. The DON acknowledged that a bruise found on the first resident prior to the skin tear was not investigated, despite it being unusual for the resident. Multiple staff interviews corroborated the pattern of rough and abusive behavior by CNA 2, as well as the failure to immediately report and investigate these incidents as required by facility policy.