Abuse and Rough Handling of Residents with Dementia by Certified Nurse Aides
Penalty
Summary
Certified Nurse Aide #1 and Certified Nurse Aide #2 engaged in inappropriate and abusive physical and mental interactions with two residents diagnosed with dementia and other comorbidities. Certified Nurse Aide #1 attempted to redirect a resident who was wandering by holding onto the resident's upper arms from behind and pushing them forward toward a chair. This aggressive handling caused the resident to lose balance and fall to the floor, resulting in a superficial abrasion to the right flank. The resident's care plan indicated the need for a calm, gentle approach and redirection during agitation, but these interventions were not followed during the incident. Certified Nurse Aide #2 was observed responding aggressively to another resident who had unplugged a power cord. The aide physically redirected the resident to a chair, held the resident down with body weight, and continued to maintain close proximity while taunting and blocking the resident, leading to further agitation. Later, when the resident removed a power cord from a medication cart, Certified Nurse Aide #2 donned gloves and physically struggled with the resident to retrieve the cord, pushing the resident up against a wall and engaging in a physical altercation. The resident's care plan also called for a calm approach and redirection, which was not adhered to during these events. Multiple staff interviews and video footage confirmed that both aides used physical force and engaged in mentally abusive behaviors, such as taunting and intimidation, rather than following established protocols for managing residents with dementia. The actions of the aides were described by staff, including the DON, LPN, and other witnesses, as physically and mentally abusive, and not in compliance with the facility's abuse prevention policies. The residents involved were known to wander and did not exhibit aggressive behaviors, and their care plans did not call for physical restraint or forceful redirection.