Failure to Protect Resident from Abuse and Neglect During Staff Altercation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to protect a resident from abuse and neglect during a verbal altercation with another CNA. The resident, a male with diagnoses including bipolar disorder, schizophrenia, and spinal stenosis, had intact cognition and a history of behavioral symptoms. He was on one-to-one supervision due to previous behaviors. On the day of the incident, the resident engaged in escalating verbal exchanges with staff, including cursing and making threats. Despite being under supervision, the resident entered the activity room and became involved in a heated argument with a CNA, who subsequently sprayed him with pepper spray. The supervising CNA did not intervene or attempt to remove the resident from the situation, later stating she was in shock and unsure of what to do. Multiple staff and residents witnessed the incident, and several staff members reported hearing the CNA threaten to use pepper spray earlier in the day. The resident reported burning sensations to his head and eyes and was sent to the hospital, where no injuries were documented. Staff interviews confirmed that the supervising CNA did not attempt to de-escalate the situation or seek help, and that the CNA who used the pepper spray had previously expressed intentions to do so if provoked. The incident resulted in other residents and staff experiencing coughing due to exposure to the spray. The facility's policy prohibits abuse, neglect, and the use of weapons such as pepper spray by staff. The failure to intervene and protect the resident from harm, as well as the use of pepper spray by a staff member, constituted a violation of resident rights and placed the resident and others at risk for harm. The deficiency was identified as past noncompliance, with the noncompliance period beginning and ending within a specified timeframe.