Failure to Protect Residents from Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from physical abuse and neglect by a certified nursing assistant (CNA). In the first incident, a female resident with moderate cognitive impairment, blindness in one eye, and other significant medical conditions was subjected to physical abuse in the shower room. Two nursing assistants (NAs) witnessed the CNA put soap directly on the resident's face, causing soap to run into her eyes and resulting in the resident expressing discomfort and irritation. The incident was not reported immediately by the witnesses due to fear of retaliation from the CNA. In the second incident, a male resident with severe cognitive impairment, hemiplegia, and a history of aggressive behaviors was physically restrained by the same CNA during peri-care. Witnesses described the CNA using her knee and hands to pin the resident's arms and chest, and placing a hand around his throat while verbally abusing him. The resident was observed to become distressed, repeatedly asking for the CNA to stop. Again, the incident was not reported immediately by the staff present, citing fear of the CNA and her connections outside of work. Both incidents were eventually reported to the facility's abuse coordinator after a delay. Interviews and witness statements confirmed that staff were trained to report abuse immediately but failed to do so in these cases. The residents involved had significant cognitive and physical impairments, making them particularly vulnerable. The facility's failure to ensure timely reporting and protection from abuse constituted noncompliance and placed residents at risk of harm.