Resident Subjected to Rough and Disrespectful Care During ADL Assistance
Penalty
Summary
A cognitively and visually impaired resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia was subjected to rough and disrespectful care by two CNAs during an in-bed change. The resident, who was non-verbal and dependent for activities of daily living, was observed on video being physically handled in a rough manner, including having their head and torso forcefully pushed down while actively resisting and crying out. The CNAs were also heard threatening the resident to stop screaming and one was seen slapping the resident's face during care. The resident was visibly frightened, screaming, and resisting throughout the incident, but care continued without intervention from a nursing supervisor. The facility's internal incident report did not accurately document the full extent of the resident's distress, including the audible screams, resistance to care, threats, and the slap to the face. Interviews with staff revealed a lack of specific training on managing behaviors associated with dementia or de-escalation techniques. The CNAs involved did not recognize the resident's resistance as a behavioral response and did not employ appropriate interventions to address the resident's distress. One CNA admitted to being too rough and not receiving dementia-specific training, while the other acknowledged pushing the resident's head down and tapping the resident's cheek, later admitting this was inappropriate. Facility leadership, including the administrator and director of nursing, reviewed the video and acknowledged that the actions did not meet facility standards, but did not clearly identify the actions as abuse. The facility's policy emphasizes the right of residents to be treated with respect and dignity and to be free from mistreatment, but these standards were not upheld during the incident. The lack of appropriate assessment, intervention, and documentation contributed to the failure to ensure the resident's right to a dignified existence and respectful care.