Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. In the first incident, a female resident with a history of stroke, severe cognitive impairment, and significant physical limitations required moderate to maximal assistance with activities of daily living. On the morning of the incident, a CNA, identified as agency staff, assisted the resident with morning care. During the process, the CNA grabbed the resident by the arm, resulting in a skin tear on the resident's left forearm. The resident reported that the aide was being too rough and that she had told the aide to stop. A roommate corroborated that the resident was vocalizing distress and that the aide continued to dress her despite her protests. The facility did not have a personnel file for the agency CNA involved in the incident. In the second incident, another female resident with moderately impaired cognition, limited mobility, and a need for extensive assistance with bathing was left unattended in the shower by a CNA. The CNA left the resident alone to retrieve a towel, during which time the resident remained unsupervised. The CNA later reported that the resident refused care and became physically aggressive, after which the CNA left the facility before the end of her shift. The resident was later assisted out of the shower by another staff member. Facility policy explicitly states that residents requiring shower assistance are never to be left alone during bathing. Both incidents were confirmed through interviews, record reviews, and facility documentation. The facility's own policies require staff to use safe lifting and movement techniques and to remain with residents during bathing. The actions and inactions of the CNAs involved directly resulted in the residents not being protected from abuse and neglect, as required by facility policy and regulatory standards.