F0600

D

Resident Physically Abused by CNA During Agitated Care Episode

Englewood, Florida Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by staff during the provision of care. The facility’s Abuse, Neglect, Exploitation & Misappropriation policy defines abuse as the willful infliction of injury, including physical abuse such as hitting, slapping, and punching, and states that such acts are strictly prohibited. Despite this policy, a CNA was reported to have intentionally struck a resident’s right forearm multiple times during care, resulting in visible redness and linear markings consistent with a grab or excoriation-type injury.

The resident involved had a history of traumatic subdural hemorrhage, diffuse traumatic brain injury, ADHD, and a psychotic disorder with delusions, with a BIMS score indicating moderate cognitive impairment. The resident’s care plan documented mood problems related to traumatic brain injury, unpredictable behaviors, a potential for traumatization due to prior storm/hurricane evacuations, and communication problems requiring staff to allow adequate time to respond and not rush. The care plan also noted that the resident was dependent on staff for emotional, intellectual, physical, and social needs, with an intervention for all staff to converse with the resident while providing care. During the incident, the resident became agitated and physically aggressive while being assisted to bed, including kicking and hitting staff.

Multiple staff interviews described the sequence of events leading to the abuse. One CNA reported that another CNA repeatedly tapped on the resident’s plate while insisting he finish his food, wiped his mouth aggressively when he refused and spit food out, and then proceeded with a transfer to bed despite the resident’s refusal and agitation when seeing the mechanical lift. During the transfer, the resident kicked one CNA and hit the other, after which the accused CNA allegedly grabbed the resident’s arm, twisted it so the forearm was exposed, and hit the same spot on the forearm four to five times while laughing and grinning. The reporting CNA, as well as other staff, observed a red mark on the resident’s right forearm, and photographic evidence documented these red marks. The resident stated that nurses slapped his arm multiple times, and a family member reported being told that someone had tapped his arm repeatedly while saying “don’t do that.” Additional staff, including LPNs, confirmed being told that the resident had been slapped on the arm and that they observed redness on the forearm. A primary care note documented localized erythema with superficial linear markings on the volar aspect of the right forearm, consistent with friction, a grab mark, or excoriation-type injury.

Further interviews revealed that the accused CNA denied hitting the resident and instead alleged that the reporting CNA had pinched the resident’s feet during care. However, the reporting CNA stated she had previously seen the accused CNA smack residents’ hands in a manner similar to smacking a child, though not as aggressively as in this incident. Staff accounts also indicated that care was continued despite the resident’s verbal refusals and escalating agitation, and that one LPN, when informed of the incident and shown the resident’s arm, stated she did not want any part of it and left the room. Another LPN reportedly responded to the description of the incident and the redness on the arm by saying she hoped it would go away. These actions and observations collectively demonstrate that the resident was not kept free from physical abuse as required by the facility’s abuse policy.