Failure to Provide Gentle Care During Repositioning Results in Resident Injury
Penalty
Summary
Staff failed to provide gentle care when repositioning a resident with severe cognitive impairment and a history of agitation and aggressive outbursts. The resident, who was dependent on staff for personal hygiene and bed mobility, required two staff members for care and specific interventions to prevent injury and agitation. During incontinence care, one nurse aide grasped the resident's shoulder and wrist and pulled the resident toward herself, despite the resident being slightly resistive and not following commands. The resident was observed to grimace during this interaction, and later assessment revealed swelling and bruising of the left hand, with an x-ray confirming a minimally displaced distal ulnar fracture. Interviews and documentation indicated that the nurse aide involved was in a hurry, became frustrated, and used excessive force while turning the resident. The aide's statements were inconsistent and did not clarify the specifics of the incident. The facility's policy defined abuse as the willful infliction of injury resulting in harm or pain, and the actions taken by the staff during this incident did not align with the required gentle and unhurried approach outlined in the resident's care plan.