Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from physical abuse during personal care. The resident, an elderly female with severe cognitive impairment due to dementia and multiple comorbidities, was dependent on staff for all activities of daily living. On the morning in question, two CNAs entered the resident's room to change her brief. The resident expressed a desire to sleep and refused care, but the CNAs proceeded. According to the resident and her roommate, one CNA forcefully grabbed the resident's right hand and pulled her thumb backward, causing the resident to scream in pain. The roommate, separated by a curtain, heard the incident but could not see it. Video and audio evidence captured the resident shouting and screaming during the care episode, with the curtain drawn to block the camera's view. Following the incident, the resident was observed to have swelling and bruising on her right thumb, which was later diagnosed at the hospital as a comminuted, mildly displaced fracture of the base of the right first digital proximal phalanx with extension to the first digit joint. Staff statements indicated that the injury was not immediately reported, and the CNAs involved did not provide a clear account of how the injury occurred. The facility's records showed that the injury was only discovered when the resident was unable to use her hand to hold her phone, and subsequent assessment confirmed the injury. The facility's abuse policy required immediate reporting of suspected abuse or injuries of unknown origin, but this protocol was not followed in this case. Interviews with other staff and residents indicated that the incident was isolated, with no other reports of abuse or injury by staff. However, the failure to protect the resident from physical harm during care, the lack of immediate reporting, and the attempt to obscure the incident from video surveillance by drawing the curtain contributed to the deficiency. The event was determined to be an Immediate Jeopardy situation due to the serious injury and the failure to ensure the resident's right to be free from abuse.