Failure to Protect a Resident From Staff-Inflicted Abuse and Inaccurate Fall Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse and to ensure accurate reporting of a fall event. Resident B, who was moderately cognitively impaired with diagnoses including depression, anxiety, and unspecified dementia, used a wheelchair and walker for mobility and had not exhibited behaviors during the MDS assessment period. A facility-reported incident and subsequent review of hallway video footage revealed that a CNA (CNA 2) was aggressive with the resident and caused him to fall from his wheelchair in a common area on the locked dementia unit. Video footage showed Resident B sitting in his wheelchair near the central nurse’s station, removing linens from a linen cart, throwing them on the floor, and flipping the cart so that it and additional linens fell around him. CNA 2 exited a nearby resident room, then aggressively grabbed the back of Resident B’s wheelchair with both hands and purposely, forcefully pulled the wheelchair backward toward the nurse’s station with two jerking motions. After the second pull, Resident B fell from the wheelchair, landing on his buttocks and then onto his back, partially out of camera view. CNA 2 stood over the resident briefly, then walked away to right the linen cart and return linens to it, moved the cart down the hallway, and re-entered a resident room, leaving Resident B on the floor. The video further showed that CNA 2 continued to leave Resident B on the floor while she wheeled another resident around him and walked past him multiple times, including standing at the nurse’s station looking down at him and pointing toward the linen cart, without providing assistance. Another resident in a wheelchair attempted to maneuver around Resident B, who tried to scoot out of the way and eventually sat up on his buttocks, appearing to yell toward the nurse’s station. CNA 2 later walked around Resident B and mimed tipping the linen cart and throwing linens without actually touching them, while Resident B remained on the floor. RN 3, who had been off the unit on lunch during the incident, stated that when she returned, Resident B was already sitting on the floor with his wheelchair in front of him, and she was told by CNA 2 that the resident had flipped the linen cart on himself and slid to the floor; she followed fall protocol based on that account. Resident B reported no memory of the fall. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included mental abuse such as humiliation and harassment.
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