Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A certified nursing assistant (CNA) used abrupt force to place a male resident with moderate cognitive impairment and behavioral symptoms onto his bed. The resident, who had diagnoses including hepatic encephalopathy, dementia, anxiety disorder, and delusional disorder, was known to be resistive to care and exhibited aggressive behaviors such as threatening and attempting to strike staff. On the day of the incident, the resident was observed ambulating in the hallway without proper clothing, entered another resident's room, and became aggressive when redirected by staff. During the attempt to guide the resident back to his room, the CNA held both of the resident's arms behind him, pushed him forcefully onto the bed, and pressed on his chest when the resident tried to get up. The incident was captured on video and witnessed by the resident's family member, who reported it to the facility administrator. Interviews with staff and review of video footage confirmed that the CNA used forceful physical contact during the transfer, which was not in accordance with the resident's care plan interventions for managing resistive and aggressive behaviors. The care plan specified the use of reassurance, clear explanations, and leaving and returning later if the resident resisted care, rather than physical force. The CNA did not request assistance from other staff during the incident, despite the resident's known behavioral challenges. The facility's investigation and interviews with other staff and residents indicated that this was the only incident of abuse involving this resident, and no physical injury was noted upon assessment. However, the use of forceful physical contact constituted a failure to ensure the resident's right to be free from abuse, neglect, and physical punishment, as required by facility policy and regulatory standards.