Failure to Protect Resident From Staff Physical and Emotional Abuse During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from staff-to-resident physical and emotional abuse, contrary to its Abuse Prevention Program, which affirms residents’ rights to be free from abuse, mistreatment, and willful infliction of injury or mental anguish. The resident had significant medical conditions, including congestive heart failure, bilateral above-the-knee amputations, neuromuscular bladder dysfunction, generalized anxiety, depression, and a buttocks pressure ulcer, and was dependent on staff for toileting and hygiene. During an early morning episode of incontinence with a large amount of diarrhea, two night-shift agency CNAs entered the resident’s room to provide care. The resident reported that the CNAs became upset about the extent of cleanup required, called him derogatory names, and one CNA with very long fingernails pinned him down by holding his arms, causing skin tears. The resident stated that when he attempted to drink his pop, the same CNA struck his hand so hard that the drink flew out of his hand. A CNA who arrived on the next shift reported hearing the resident yelling, finding him crying uncontrollably and extremely distraught, and observing two fresh skin tears on his left arm shaped in a manner consistent with fingernail injuries. She also observed that the resident’s bedding and pillow were covered in feces, feces were on the floor, and the pop bottle was across the room with dried, sticky pop on the floor, consistent with the resident’s account that the CNAs left him soiled and had struck the bottle from his hand. An RN who completed a skin assessment after the allegation documented dried blood on the resident’s left arm, a skin tear on the left forearm, and an adjacent crescent-shaped indentation that broke the skin and appeared consistent with a fingernail injury. One of the involved agency CNAs admitted that when the resident became upset and combative, she held his wrists down on the bed and that they left him soiled until the next shift. The DON confirmed that staff should never antagonize or restrain a resident by holding their arms, that this resident was typically cooperative when treated respectfully, and that the resident was not known to make false allegations, corroborating that the resident alleged both emotional and physical abuse by staff.
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