Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from physical abuse by a staff member. Facility policy on abuse, neglect, and exploitation, last revised in January 2025, defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifies that physical abuse includes hitting and slapping. Despite this policy, on the morning of 01/14/26, a certified nurse aide (CNA #1) was reported to have slapped a resident in the face in an alcove area near the dirty utility room and the resident’s room. The resident, admitted in September 2025 with dementia with behavioral disturbances, major depression, and legal blindness, had a recent MDS showing a BIMS score of 3/15, indicating severe cognitive impairment. Multiple staff observations and interviews described the events surrounding the incident. A nurse (Nurse #1), while putting away the resident’s clothes, heard someone say, “why did you do that?” and went to the alcove, where she found the resident holding their face with both hands, with a red area on the right side of the face and a scratch near the right eyebrow. CNA #2 reported to Nurse #1 that she had just witnessed CNA #1 slap the resident in the face and stated she saw the slap and observed a red mark and a small cut on the right side of the resident’s face. A medical records employee reported hearing commotion near the dirty utility room and a sound like a slap around the same time. The staff development coordinator (SDC) and the DON each separately assessed the resident shortly after and both observed a small pink/red scratch and red marks on the right side of the resident’s face; the resident told them that someone had hit or slapped them in the face, though could not identify who. CNA #1 denied slapping the resident but admitted to pushing the resident. In interviews with the SDC, DON, and police, CNA #1 stated that the resident was in front of her near the soiled utility room, would not move, and was grabbing for her face or glasses, and that she pushed the resident away by the shoulders. The police report documented that the resident described having gotten into a “tussle,” pointed to the right eye, and stated they were hit in the eye, and the officer observed two small red marks on the right side of the resident’s head near the eye. The facility’s own HCFRS report recorded that CNA #1 had been witnessed slapping the resident, that the resident had red markings on the right side of the face, reported facial pain, and received pain medication. Based on these observations and statements, surveyors determined that the facility failed to ensure the resident was free from physical abuse, and that, under the reasonable person concept, a cognitively impaired resident would experience emotional upset after being slapped by a caregiver.
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