Resident Forced to Shower Against Will by Staff
Penalty
Summary
A deficiency occurred when staff members failed to protect a resident from abuse. The resident, who had a history of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, was care planned for behavioral issues and a tendency to refuse assistance with transfers and showers. On the day of the incident, the resident refused multiple offers for a shower from a CNA, who then notified the assigned RN. The RN instructed the CNA not to ask for consent but to proceed with the shower regardless of the resident's wishes. Subsequently, the RN and another CNA physically removed the resident from bed and forced her into the shower, despite her vocal objections and resistance. The resident expressed distress during the incident, stating she was cold and did not want her hair wet, and was described as angry afterward. Interviews and documentation confirmed that the resident was pulled out of bed by her arms while she was yelling to stop. A bruise on the resident's arm was investigated but determined to have been present prior to the incident. Staff interviews revealed that it was not standard practice for nurses to perform showers and that refusals were typically respected, with documentation of the refusal if the resident continued to decline after being approached by both CNA and nurse. Personnel records for the involved staff showed prior disciplinary actions for discourtesy, insubordination, and failure to follow procedures. Both staff members involved in the incident had completed abuse prevention training earlier in the year. The facility's investigation substantiated the abuse allegation, confirming that the staff members forced the resident to shower against her will, in violation of facility policy and resident rights.