Abusive Shower Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from abuse during personal care. The resident had a BIMS score of 1 and diagnoses including dementia, Alzheimer's disease, and depression, and was dependent on staff for ADLs and hygiene. According to the facility’s internal investigation and witness statements, during an evening shift the resident required two showers due to bowel incontinence. During the second shower, the resident became agitated and attempted to pull on the shower hose and pipes. In response, one LNA, who reported feeling frustrated, sprayed the resident in the face with freezing cold water while another LNA assisted as the resident tried to rip the hose from the first LNA’s hands and continued pulling on the pipes. Per the witness statement, both LNAs involved in the shower incident later laughed about what had occurred while giving report to another staff member, and the resident expressed a desire to apologize to someone without knowing to whom. A subsequent addendum to the investigation documented that the resident was later noted to have five bruises on the left forearm in healing stages, which were assessed as likely related to staff holding the resident’s arm to prevent them from grabbing the water hose during the same shower incident. The resident was reported as having no recollection of the incident and no pain at the time of assessment. The DON confirmed during interview that the abuse occurred and stated that the allegation was substantiated.
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