Failure to Prevent Physical Abuse During Resident Care
Penalty
Summary
The facility failed to prevent physical abuse of a resident who was cognitively intact and had a history of refusing care and being physically aggressive with staff. The resident's care plan directed staff to educate her about care options, give her time and space if she was resistive, and re-approach in a calm manner. On the day of the incident, a CNA did not follow these approaches when the resident became upset about being given a brief instead of pull-ups. Instead of walking away, seeking assistance, or complying with the resident's request, the CNA held the resident's wrists to prevent her from hitting, resulting in a 4 cm bruise to the resident's left wrist and emotional distress. Interviews and documentation confirmed that the resident was upset after the incident, reporting bruises on both wrists and expressing emotional upset. The CNA involved stated she was trying to prevent being hit, but did not follow the facility's protocols for managing agitated or combative residents. The facility's abuse prevention policy prohibits physical abuse and requires staff to use non-restrictive interventions. The incident was reported, investigated, and the CNA was terminated, but the deficiency centers on the failure to prevent physical abuse and follow established care protocols.