Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident by pinching the resident's nose, resulting in visible injuries including bruising and discoloration to the nose, forehead, and above the right eyebrow. The incident took place during morning activities of daily living (ADL) care, after the resident verbally abused the CNA with racial slurs. The CNA admitted to pinching the resident's nose and also reported that the resident hit his head on the bed rail during care. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, restlessness, agitation, and vascular dementia, was rarely or never understood and had not exhibited physical or verbal behaviors during the look-back period according to the Minimum Data Set (MDS). The licensed practical nurse (LPN) was present outside the resident's room during the incident and was informed by the CNA about the verbal abuse. The LPN offered the CNA the option to switch assignments, but the CNA declined and stated she had something for the situation. After the incident, the CNA told the LPN in a joking tone that she had pinched the resident's nose. The LPN initially responded that she was not doing any incident reports that day, but later, upon noticing the resident's facial injuries during wound care, decided to report the incident to the supervisor. The CNA attempted to provide a cream to cover up the injury, but the LPN refused to apply it. The incident was not reported to administration until several hours later, after the RN supervisor was notified. The CNA was then removed from the unit and admitted to pinching the resident's nose, stating she was triggered by the resident's language. The resident was assessed and found to have multiple bruises on the face but denied knowing what happened and did not verbalize pain. The facility's policy required staff to be trained in abuse prevention and to report and remediate abuse immediately, but in this case, there was a delay in reporting and a failure to protect the resident from physical abuse.
Removal Plan
- The staff member who reported pinching the resident's nose was removed from care, a statement was obtained, and she was immediately put on administrative leave.
- A report was completed and provided to the authorities including Certification, Veterans Association, Ombudsman, VA contract monitor, Medical Director, and local authorities.
- The resident had a psychosocial visit completed by the Social Services Director.
- The resident was provided safety and interviewed for any feelings of fear or anxiety.
- The resident had pain monitored and was re-evaluated for side rail need; 1/4 rails were removed.
- The care plan was updated to reflect that staff should discontinue care and report to the nurse when a resident's physical or verbal behaviors escalate.
- Other residents cared for by the accused staff member were interviewed or had body checks completed by a licensed nurse; no concerns or skin issues were noted.
- Interviews were completed with other staff members providing care on that unit; no unusual findings or discoloration on the resident's nose were identified.
- The resident's responsible party was notified and the occurrence explained in full.
- A review of risk reports, grievance process, and resident council minutes was completed; no concerns related to potential abuse were identified.
- A root cause analysis was conducted, determining that the involved staff member did not follow protocol regarding residents who are combative or abusive.
- The QAPI committee determined that re-education was warranted on the abuse policy, which was started.
- All staff were re-educated on the abuse policy, including types of abuse, what and when to report abuse, and what to do when a resident is abusive verbally/physically.
- Policy and procedure were reviewed and updated with emphasis on removing self from a resident with escalating behaviors and notifying the nurse for assistance/guidance.
- Hiring practices were reviewed to include background and reference checks and orientation that includes abuse prevention.
- The accused staff member's file was reviewed and found complete as per practice.
- The accused staff member was immediately placed on administrative leave and, following investigation, employment was terminated.
- Questionnaires (audits) testing staff knowledge of abuse prevention and handling escalating behaviors will be completed randomly, with results reviewed in the QAPI process until compliance is attained and maintained.