Failure to Protect Resident From Physical and Verbal Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical and verbal abuse by a CNA during personal care. The resident had hemiplegia/hemiparesis with upper and lower extremity impairment on one side and required partial/moderate assistance with toilet hygiene and transfers. During an episode of incontinence, the resident used the call light for help and was assisted by one CNA into a shower chair in the bathroom. A second CNA (CNA #1) then became involved in the care and insisted the resident take a shower, which the resident refused, leading to an escalating argument. According to the resident, CNA #1 yelled and cursed, scrubbed the resident very hard, was intentionally rough, and continued despite the resident’s reports of pain and requests to stop and get another caregiver. The resident reported that CNA #1 locked the shower chair brakes to prevent access to the call light and that the interaction caused pain during the incident and soreness afterward. Another CNA (CNA #2) reported hearing CNA #1 yelling and arguing with the resident, observed her scrubbing the resident and a wound while the resident said it hurt and asked her to stop, and heard CNA #1 refuse to stop. CNA #2 also reported hearing CNA #1 call the resident an “asshole” and state that the resident had “shit” in the genital area. CNA #1 acknowledged telling the resident they needed to get the “shit” off and admitted saying that if the resident was going to be an “ass,” she could be an “ass” too. CNA #1 described the resident yelling and kicking during care and stated she sprayed the resident with cold water accidentally, then began washing the resident and stopped when asked, but her account conflicted with the resident’s and CNA #2’s reports that she continued despite the resident’s objections. A nurse entered the room during the incident and told CNA #1 to stop talking to the resident, which ended the interaction. The DON later stated she considered the incident a concern and that staff who witness abuse are expected to intervene and report immediately, and it was noted that no formal plan of correction was implemented following this incident, despite the facility’s written abuse policy stating that no abuse or harm of any type will be tolerated and that veterans will be protected from abuse, neglect, and harm.
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