Failure to Protect Residents From Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, resulting in physical harm to one resident and verbal abuse of another. One resident with acute embolism and thrombosis of the right femoral vein, history of pulmonary embolism, fibromyalgia, major depressive disorder, and dementia with agitation had a quarterly MDS showing moderate cognitive impairment and dependence on staff for transfers and significant ADL assistance. Facility documents show that this resident reported asking a CNA for assistance back to bed, and the CNA told her she could put herself in bed and then twisted her arm. A head-to-toe assessment identified a skin tear on the right arm where the resident reported the CNA twisted her arm, and a subsequent skin assessment documented bruising in a fingerprint pattern around the skin tear. During multiple later observations and attempted interviews, the resident either did not answer questions about the incident or refused to discuss it. The deficiency also includes an incident of verbal abuse toward another resident who had been admitted with essential hypertension, GERD, asthma, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. The Social Worker District Coordinator reported being informed by staff that a CNA yelled at this resident to “shut up.” The SDC interviewed the resident, who is nonverbal, and the resident confirmed the allegation by nodding yes. The Administrator was notified and also interviewed the resident, who again confirmed the verbal abuse allegation by nodding. The facility’s written policies on Abuse, Neglect and Exploitation and on Reporting Reasonable Suspicion of a Crime state that the facility will prohibit and prevent abuse, neglect, and exploitation of residents and will analyze occurrences to determine why abuse occurred and what changes are needed to prevent further occurrences, as well as report any reasonable suspicion of a crime against a resident.
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