Failure to Protect Resident From Verbal and Physical Abuse During Shower Care
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from verbal and physical abuse when a certified nursing assistant (CNA) was verbally and physically abusive during and after a shower. The resident involved had dementia, a psychotic disorder, and an anxiety disorder, but was assessed with a BIMS score of 12/15, indicating intact cognitive abilities for daily decision making. The resident required assistance with most self-care activities, including dependence for toileting, oral hygiene, and bathing. Facility documents showed that on the date of the incident, the CNA repeatedly called the resident a “witch” and, while transporting the resident in the corridor after a shower, rolled the resident in front of a fan, causing the resident to yell due to discomfort from the cold air. Interviews conducted during the survey provided additional context. The resident later stated that no staff member had mistreated her and described herself as having a bad temper and being very vocal, which she felt irritated people. Another CNA reported that the resident typically took showers without conflict, sometimes stating she was cold during care, and described the resident as not aggressive but impatient during care. An LPN explained that when residents exhibit behaviors, CNAs are instructed to ensure safety, step away, report behaviors to the nurse, and return later. Despite these expectations and prior abuse in-services completed by the CNA involved, the documented incident of name-calling and exposure to cold air during transport constituted a failure by staff to protect the resident from verbal and physical abuse.
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