Failure to Investigate and Protect Residents From Alleged Rough and Abusive Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from alleged physical and mental abuse and to ensure a resident environment free from abuse, as required by its Abuse, Neglect, and Exploitation policy. The policy states that an immediate investigation is warranted when suspicion or reports of abuse occur and that the facility must respond immediately to protect alleged victims and prevent further contact with the alleged perpetrator. Despite this, the facility did not initiate any investigations or documented protective measures after repeated resident and staff reports that one CNA was rough with care and that residents did not want this CNA to provide care or enter their rooms. One cognitively intact resident with multiple medical conditions, including a left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis, reported being physically and mentally abused since admission. This resident stated the CNA was rough with cares, yelled at the resident for incontinence, refused to get the resident out of bed to use the bathroom, used a bedpan instead, and pinched or jabbed the resident in the hip during care. The resident reported these concerns directly to the nursing home administrator within days of admission and specifically stated feeling physically and mentally abused. The resident reported that the administrator did not take the allegations seriously, suggested the resident might be anxious or depressed, and did not follow up. The medical record contained a provider note documenting the resident’s concerns about care and desire to transfer, and an administrator note referencing a care conference and the resident appearing anxious and tearful, but no documentation of an abuse investigation or specific follow-up on the rough care allegations. Additional residents with varying levels of cognition and significant medical diagnoses also reported that the same CNA was rough with cares and that they did not want this CNA in their rooms. One resident and that resident’s family member reported the CNA was mean and rough with care and communication; another resident described the CNA working too fast and being rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA was aggressive during urinal assistance and pushed the urinal too hard, causing pain; and another resident stated the CNA was mean, rough, and caused fear. Multiple CNAs and a unit manager LPN confirmed that several residents complained the CNA was rough, that some residents would not allow the CNA in their rooms, and that these concerns were reported to nursing and administration. Despite these repeated reports, the administrator denied receiving reports that the CNA was rough, and there were no grievances, facility-reported incidents, or investigations completed related to these concerns, indicating the facility did not implement its abuse policy or ensure residents were protected from potential abuse.
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