Pillowcase Placed Over Resident’s Face During Care
Penalty
Summary
The deficiency involves staff placing a pillowcase over a resident’s face during care, constituting mental abuse. The resident involved had diagnoses including cerebral palsy, severe intellectual disability, and muscular dystrophy. During an interview, a CNA stated that staff should not have placed a pillowcase over the resident’s face and that appropriate action would have been to stop the behavior, remove the pillowcase, ensure the resident was okay, remove the staff from resident care areas, and report the incident to the Administrator as abuse. The facility’s abuse policy in effect at the time stated that residents have the right to be free from abuse. The Social Service Director reported that she entered the resident’s room after hearing the resident yelling and observed two CNAs preparing to transfer the resident from bed to wheelchair, with the resident’s entire face covered by a pillowcase, though the head was not inside the pillowcase. She instructed the CNAs to stop and remove the pillowcase, which one CNA did before completing the transfer. One CNA told the Social Service Director that the resident had spit at staff and she did not want to be spit on. Another CNA later reported witnessing a pillowcase over the resident’s face and demonstrated to the Administrator that it had been draped from the top of the forehead to below the chin. These observations and statements formed the basis for the finding that the resident was not protected from mental abuse by staff.
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