Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during care. On the evening of December 9, 2025, two CNAs were assisting resident R2 into bed when R2, who has severe dementia with anxiety and behavioral disturbances and is documented as having severe cognitive impairment on the MDS, reached out and grabbed one CNA’s head. According to a witness statement from the assisting CNA, the primary CNA responded by striking R2’s hand and telling R2 not to grab her head. The alleged perpetrator CNA’s written statement in the facility’s investigation file differs, indicating that she only removed R2’s hand from her head. The facility’s investigation report documents that R2 grabbed the CNA’s head and that the CNA immediately responded by grabbing and redirecting R2’s hand away from her head. R2’s EMR includes a health status note from the date of the incident indicating that a CNA reported an alleged incident during a transfer in R2’s room and that R2 was assessed for injuries and vital signs were obtained. Subsequent observation on January 15, 2026, showed R2 lying in bed, unable to respond to questions due to severe cognitive impairment. Interviews conducted later revealed that the CNA alleged to have struck R2’s hand was no longer employed at the facility and declined to discuss details of the incident, citing concern about self-incrimination. The Administrator/Abuse Coordinator later stated that the CNA had instinctively moved R2’s hand away from her long hair and confirmed there was no injury to R2. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy states that residents have the right to be free from physical abuse and that the facility is committed to protecting residents from abuse by anyone and to maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional challenges.
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