Failure to Prevent Physical Abuse During Provision of Care
Penalty
Summary
Facility staff failed to protect a resident from physical abuse when a CNA slapped the resident on the leg during care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program and Clinical Protocol policy, revised April 2021, stated the facility would develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. An investigation dated 1/28/26 documented that staff notified the administrator that a nurse assistant had witnessed a CNA hit a resident on the leg five times, and witness statements and resident interviews were collected. The investigation concluded the allegation was substantiated. The resident involved had a Significant Change MDS dated 12/09/25 showing severe cognitive impairment, daily rejection of care, and diagnoses including non-Alzheimer’s dementia and depression, with the resident always incontinent of bowel and bladder. The resident’s care plan, dated 04/08/24, identified impaired cognitive function/dementia or impaired thought process, ADL self-care performance deficit, physical aggression, and bowel and bladder incontinence. Progress notes from 1/24/26 to 1/28/26 did not contain documentation that the CNA slapped the resident on the leg while providing care. Interviews provided further detail of the incident. The resident’s roommate reported not seeing the event due to the curtain being closed but stated he/she could hear it. The CNA involved stated that while helping the resident to bed, the resident resisted care, the brief was soaked with urine, and the CNA was working alone; the CNA denied ever hitting or slapping anyone and reported being surprised by the accusation. The administrator reported receiving a call from an RN that a nurse assistant had witnessed the CNA strike the resident five times on the leg while performing pedicare. The nurse assistant witness stated that while walking down the hall, he/she heard a smacking noise, looked into the room, and saw the resident hit the CNA and the CNA hit the resident on the outer part of the left thigh with an open hand, with a total of about five hits or slaps, and noted that although the resident was known to be a “fighter” during care, staff were not supposed to hit residents back.
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