Resident Physically and Verbally Abused During Transfer
Penalty
Summary
A deficiency occurred when a registered nurse supervisor physically and verbally mistreated a resident during a transfer. The resident, who had chronic obstructive pulmonary disease, vertigo, and was dependent on staff for transfers, was being assisted by staff using a sit-to-stand device. The resident became fearful and resisted the transfer, at which point the nurse supervisor placed their hand around the resident's neck, reportedly squeezing hard and causing pain. Multiple certified nurse aides witnessed the supervisor holding the resident by the neck in an aggressive manner, despite the resident's repeated requests to let go due to pain. The supervisor also raised their voice at the resident and responded to the resident's threat to hit them by stating they would hit the resident back. The incident resulted in a visible scratch and redness on the resident's neck, as documented by nursing staff and observed by police. The resident complained of neck pain and emotional distress, expressing a desire to call the police and have the supervisor arrested. Staff interviews consistently described the supervisor's actions as rough, aggressive, and excessive, with no indication that the resident was at risk of falling at the time the supervisor grabbed their neck. The resident and their spouse both reported ongoing fear and distress following the incident, with the resident ultimately choosing to leave the facility against medical advice due to feeling unsafe. The facility's internal investigation initially did not identify the supervisor's actions as abuse, citing a lack of intent to harm and conflicting staff perceptions during a reenactment. However, multiple staff statements and the resident's own account indicated that the supervisor's physical and verbal conduct caused actual harm and mental anguish to the resident. The incident was reported to the police, and the supervisor was suspended and subsequently resigned. The deficiency was cited for failure to protect the resident from abuse, resulting in actual harm.