Failure to Prevent Verbal and Physical Abuse of Resident by Staff
Penalty
Summary
A deficiency occurred when facility staff failed to prevent verbal and physical abuse of a resident with dementia, resulting in psycho/social harm. The resident, who had a history of dementia, anxiety, depression, and chronic pain, was involved in an incident with a CNA who was also the administrator's son. The resident reported being taken into her room, having her arms and chest squeezed from behind until it hurt, and having her wheelchair taken away. Multiple interviews with staff and the resident indicated that the CNA became frustrated after being called names by the resident, took her to her room, and removed her wheelchair, leaving her upset and unable to move independently. The resident continued to complain of pain in her right shoulder following the incident. Several staff members witnessed or were made aware of the incident, with some hearing the resident yelling for her wheelchair and help. Staff statements described the CNA as having dumped the resident into bed, taken her wheelchair, and made threatening remarks about further retaliation if the resident continued to call him names. The resident was visibly upset, refused medications from one LPN due to distress, and was later moved to another unit for the remainder of the night. Staff also reported that the CNA admitted to taking the wheelchair and expressed frustration with the resident's behavior, while other staff recognized the removal of the wheelchair as a form of restraint and abuse. Despite multiple staff being aware of the incident and reporting it to administration, there was confusion and delay in the facility's response. The administrator, who was also the CNA's father, did not arrive at the facility until later in the day and took over the investigation. Some staff expressed concerns that reports of abuse were not taken seriously and that there was a culture of discouraging reporting. The resident's ongoing complaints of pain and distress, as well as the corroborating staff statements, demonstrate a failure to protect the resident from abuse and neglect as required by facility policy.