Failure to Protect Resident From Verbal Abuse and Neglect During Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse and neglect by a CNA. The cognitively intact resident, who had a BIMS score of 15/15 and required assistance with most ADLs, reported that on the day of the incident the CNA entered the room, placed a brief in the room, and was aware the resident was wet and needed assistance but did not provide care for approximately one hour. When the CNA returned, the resident requested a clean gown and flat sheet due to being wet with urine. The resident stated the CNA began yelling, saying the resident should have requested those items earlier, that she did not have time to obtain them, and that she would change the resident quickly and return later with the requested items. The resident reported the CNA yelled for about five minutes while providing care, which caused the resident to cry and feel degraded, humiliated, anxious, and uncomfortable. The resident further reported that the CNA did not return with the requested clean gown and flat sheet for approximately two hours, during which time the resident remained anxious and uncomfortable while sitting in urine. During follow-up interviews, the resident became tearful when recounting the incident and expressed sadness about being treated in that manner and wishing to be able to care for herself. Record review confirmed the resident’s need for assistance with daily hygiene and grooming. Facility leadership, including the DON and Nursing Home Administrator, reported that an investigation was conducted and that abuse was substantiated, and both acknowledged that yelling at residents constitutes verbal abuse and that making the resident wait so long for needed incontinence care and linens constituted neglect. The facility’s abuse policy states residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.
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