Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia and polyneuropathy, required total assistance with activities of daily living. On the night in question, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully twisting the resident's right arm behind their back during care, after expressing frustration and making an inappropriate comment. The resident was noted to be squirming and attempting to free their arm, and the incident was not immediately reported to the charge nurse due to fear of retaliation. Following the incident, the resident was assessed by a registered nurse, who initially found no injuries and noted the resident could move both arms without apparent pain. However, a subsequent assessment revealed slight bruising and pain when the right arm was raised. Diagnostic imaging later confirmed a dislocated right shoulder, and the resident was transferred to the hospital for treatment. The incident was reported to law enforcement, and the CNA involved was suspended and later terminated. The facility's documentation and interviews revealed that the resident required two-person assistance for care, but the incident occurred with only one CNA present initially. The other CNA, who witnessed the abuse, did not immediately report the event due to concerns about retaliation, resulting in a delay in addressing the situation. The resident's medical record indicated a history of right shoulder dislocation, and the incident led to further injury and hospitalization.