Failure to Protect Resident From Abuse and Remove Alleged Perpetrator From Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to immediately remove an alleged perpetrator from resident care after an incident was discovered. The resident was admitted with dementia, Alzheimer’s disease, generalized muscle weakness, gait and mobility abnormalities, and was assessed as a high fall risk. A recent MDS documented that the resident rarely understood and was rarely understood, and required varying levels of staff assistance with ADLs including showering, dressing, eating, toileting, and personal hygiene. The resident did not have capacity to understand and make decisions per the physician’s history and physical. During a night shift, the resident became restless and was heard chanting in a language not understood by the LVN on duty. The LVN asked the assigned CNA, who spoke the same language as the resident, what the resident was saying, and the CNA responded that the resident always did that. As the chanting increased in volume and frequency, the LVN directed the CNA to check on the resident; the CNA went into the room, spoke with the resident, and then left, reporting that the resident was okay. Later, when the chanting worsened, the LVN entered the room and observed the resident’s blanket on the floor. When the LVN picked up the blanket to cover the resident, she saw that the resident’s wrists were firmly bound together in front with a scarf, tied in a figure-eight pattern multiple times, with no wiggle room and no way for the resident to get out. The LVN took a photograph of the resident’s bound hands and then untied the scarf at approximately 3 a.m. Afterward, the LVN found the assigned CNA asleep and snoring at the nursing station. The CNA’s timecard showed she remained on duty from late evening through the end of the night shift and, by her own account and that of facility staff, she continued to work with the resident and other residents for the remainder of the shift and was not removed from the resident’s care at that time. The RMN and Administrator later characterized the tying of the resident’s hands with a scarf as physical abuse and a form of restraint, and the facility’s abuse prevention policy stated that staff accused of abuse are to be suspended until the investigation is complete.
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