Failure to Protect Resident from Physical and Mental Abuse by Staff
Penalty
Summary
A resident with severe dementia, depression, and anxiety disorder was admitted to the facility and care planned for significant assistance with activities of daily living (ADLs), including toileting and dressing. The resident was known to be frequently resistive to care and required staff to use specific approaches such as encouragement, clear explanations, and providing choices. Despite these care plan directives, video evidence captured multiple incidents where a CNA physically forced the resident into the bathroom and handled her roughly during care, resulting in the resident screaming and expressing distress. In one incident, the CNA forcefully grabbed and pushed the resident into the bathroom while she was screaming, and in another, the CNA pulled the resident up from the bed and pushed her from behind without verbal communication, despite the resident's vocal protests. Additionally, a separate incident involving an RN was captured on video, where the nurse attempted to administer medication to the same resident. The resident resisted by holding the medication in her hand and verbally expressing her refusal. The RN attempted to retrieve the medication from the resident's closed fist, during which the resident screamed and accused the nurse of breaking her fingers. The resident then struck the nurse, who responded by pointing a finger at the resident's face and verbally reprimanding her. There was no documentation in the clinical record of the medication refusal or the altercation, and the nurse did not report the incident to a supervisor as required. These incidents demonstrate that the facility failed to protect the resident from physical and mental abuse by staff. The staff did not follow the resident's care plan for managing resistive behaviors and did not adhere to protocols for reporting and documenting refusals of care or incidents of abuse. The actions of the staff resulted in dehumanization and psychosocial harm to the resident, as evidenced by the resident's distress and the nature of the interactions captured on video.