Failure to Prevent and Report Physical and Mental Abuse Resulting in Hand Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse and to ensure mandated reporting of alleged abuse. Facility policies stated that residents have the right to be free from abuse, neglect, corporal punishment, involuntary seclusion, and improper restraint, and that all employees are mandated reporters required to immediately report alleged abuse to a supervisor and administration. The administrator was responsible for implementing abuse-prevention policies, ensuring staff training, and identifying, assessing, investigating, and reporting all possible incidents of abuse within required timeframes. The resident involved had a history of CVA and parkinsonism, used a manual wheelchair, and was dependent on staff to stand. A quarterly MDS indicated the resident could understand and be understood, had no functional limitations in upper or lower extremities, and used a wheelchair for mobility, though a PT assessment documented that the resident could not propel the wheelchair 150 feet and was not capable of operating the wheelchair with full purpose due to decreased cognitive skills. The care plan included use of leg rests as needed for safe transportation while seated in the wheelchair. Observation showed the resident could slowly self-propel a short distance. On the date of the incident, a CNA (Employee E6) was observed on camera pushing the resident from the lounge/activity area down the hallway on the back wheels of a manual wheelchair without leg rests, with the front wheels elevated and the chair reclined so the resident’s feet dangled and could not touch the floor, restraining the resident from normal use of the wheelchair. A CNA witness (Employee E5) reported that the resident verbally expressed not wanting to go to her room while being pushed and was later found crying in her room, stating that someone had bent her hand and threatening to kill Employee E6 if that staff member returned to care for her. This alleged abuse was not reported by Employee E5 to an RN or LPN on either the day or evening shift as required by policy. Later that evening, an RN was called to assess the resident’s painful, swollen left hand, the physician ordered an x-ray and pain medication, and subsequent imaging revealed a fracture of the left 4th proximal phalanx of unknown origin while under facility care. The physician indicated being unaware that the resident had fallen or sustained trauma, and there was no documentation of the probable cause of the serious injury.
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