Failure to Prevent Resident Abuse and Obtain Proper Consent for Grooming
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to honor resident rights related to personal care. Several residents with cognitive impairment, dementia, depression, and high or moderate risk for abuse were involved in incidents of physical and verbal abuse. One cognitively intact resident kicked another resident in the shin after threatening them, and another resident threw water on a peer who then hit them on the arm. In a separate incident, a resident entered a bathroom while a CNA was providing care to another resident and struck that resident on the buttocks twice. Another event involved an assistant dietary manager slamming doors near two residents while loudly asserting authority, behavior that was documented as disorderly and misconduct. These events occurred despite care plans identifying certain residents as being at high or moderate risk for abuse and the facility having an abuse prevention and reporting policy defining physical, verbal abuse, exploitation, and neglect. The facility also failed to protect a resident’s rights regarding grooming and consent. A CNA, who was not a licensed cosmetologist or barber, cut a resident’s hair after knots were found while providing shower care, and the resident later stated that their hair was cut against their wishes and that it was done poorly. The resident’s guardian reported not having given consent prior to the haircut, was unaware that a CNA rather than an LPN or beautician performed the cut, and was not informed of the option to use a licensed cosmetologist who routinely visited the facility. Documentation shows that the guardian’s consent was recorded after the incident and that the resident had existing and new bruising to the hands around the same period. The resident’s admission contract states the right to refuse services unless court ordered, and the care plan notes impaired cognitive function, high risk for abuse, trauma-informed care needs, and impaired visual function, underscoring the importance of obtaining proper consent and protecting the resident from unwanted interventions.
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