Failure to Prevent Staff-to-Resident Abuse During Dependent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to prevent abuse of a resident who was dependent on staff for all activities of daily living. The resident had significant medical conditions, including cerebral infarction, type II diabetes, vascular dementia, Parkinson's disease, and dysphagia, and was on hospice care. The resident was unable to complete a cognitive assessment due to impairment and required the use of a Hoyer lift with two-person assistance for transfers, as documented in her care plan. On the evening of the incident, video evidence showed the CNA forcefully and aggressively handling the resident during a brief change and repositioning, including grabbing, pulling, and pushing the resident in a manner that appeared angry and intimidating. The CNA performed these actions alone, despite the care plan requiring two-person assistance with the Hoyer lift. The resident appeared scared and confused during the incident, as observed in the video. The CNA later admitted to using excessive force and acknowledged that the resident was fully dependent on staff for care. Interviews with staff and review of records indicated that the CNA did not request help from another CNA, who was available and routinely assisted with Hoyer transfers. The CNA stated she was not angry but found it difficult to work with the resident due to her lack of mobility. The incident was reported by the resident's family, who observed the abuse via a video camera in the room. The CNA had no prior disciplinary issues, and other staff reported no previous concerns about her conduct. The incident was confirmed through video review and staff interviews.