Failure to Prevent, Protect, and Report Resident Abuse
Penalty
Summary
On 05/04/2025, a resident with severe cognitive impairment, as indicated by a BIMS score of 99 and diagnoses including dementia, was subjected to physical abuse by a Certified Nursing Assistant (CNA). The CNA was observed on facility video surveillance restraining both hands of the resident and striking them in the head while the resident was seated in a wheelchair in the hallway. Two other CNAs were present in the hallway at the time, with one standing at the nurse's station and the other taking vital signs for another resident. Both were observed facing the direction of the incident but did not intervene, correct, or report the abuse as required by facility policy. The incident was not reported by any staff members who were present or nearby. Instead, it came to the facility's attention when a visitor reported the event to a unit liaison two days later. The unit liaison failed to immediately notify their supervisor, delaying the report until the following morning. This delay allowed the involved CNAs continued access to the abused resident and other residents in the facility for several days after the incident. Interviews with staff revealed that the CNAs who were present either denied witnessing the abuse or claimed not to recall the incident, despite video evidence to the contrary. The LPN on duty heard screaming but did not witness or report any abuse. The Director of Nursing and the Facility Administrator both acknowledged that the incident should have been reported immediately and that staff failed to follow the facility's abuse prevention and reporting policies. The facility's investigation confirmed that abuse had occurred and that staff failed to protect and report as required.