Failure to Protect Resident from Physical Abuse During Transfer
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) physically abused a resident during care. The resident, who was cognitively intact and dependent on staff for most activities of daily living, required the use of a mechanical lift for transfers and was to receive care from two staff members at all times. Despite these care plan requirements, the NA attempted to transfer the resident alone and without the mechanical lift, leading to an altercation. During this incident, the NA was witnessed by a registered nurse (RN) punching the resident in the left knee after a verbal argument and alleged aggression from the resident. The resident reported feeling unsafe and described being punched by the NA while being transferred from bed to wheelchair. The resident demonstrated the action to interviewers and stated that he retaliated by hitting the NA back. The RN corroborated the resident's account, stating she heard yelling, entered the room, and observed the NA strike the resident. The NA admitted to being alone with the resident, not using the required lift, and not following the care plan, citing lack of time to read care plans and being unfamiliar with the resident's needs. The facility's investigation confirmed that the NA failed to follow the care plan, which required two staff for care and use of the mechanical lift. The NA was alone with the resident and did not adhere to established protocols for managing residents with behavioral concerns. The incident was substantiated as physical abuse, with both the resident and RN providing consistent accounts of the event.