Failure to Prevent and Report Physical Abuse of a Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was observed on facility surveillance video restraining both hands of a resident with severe cognitive impairment and striking the resident in the head twice. The incident took place in a hallway, with the resident seated in a wheelchair. The resident had a history of dementia, hyperlipidemia, and hypertension, and was documented as severely impaired for decision-making and communication. The facility's policy requires all staff to report and immediately intervene in cases of abuse, neglect, or mistreatment. The incident was initially reported by an anonymous visitor who witnessed the event and notified a unit liaison two days after it occurred. The unit liaison did not immediately report the allegation to a supervisor, instead waiting until the following morning. Review of the surveillance footage confirmed the abuse, and it was also observed that two other CNAs were present in the hallway, facing the direction of the incident, but did not intervene or report the event. Both denied witnessing the abuse during the investigation. Interviews with staff revealed that the resident was not known to be combative and that yelling was heard during the incident, but staff did not investigate or report the situation. The director of nursing confirmed that the incident should have been reported immediately upon the visitor's disclosure. The facility's investigation concluded that abuse did occur, and the medical director confirmed that the resident had no visible injuries but emphasized that no resident should be struck by staff.