F0600

G

Failure to Protect Two Cognitively Impaired Residents From Physical Abuse by a CNA

Westfield, Indiana Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse by a CNA, affecting two residents with cognitive impairments and significant medical histories. One resident, who was legally blind and had dementia with mood disturbance, major depressive disorder, and pain, was involved in an incident during incontinence care. According to staff interviews, a CNA became involved in a combative situation with this resident while providing care. An LPN, responding after hearing the resident yelling in a muffled way, entered the room without knocking and observed the CNA with his left knee bent on the bed, both hands over the resident’s mouth and nose, and telling the resident to “shut the hell up” while raising his hands up and down over the resident’s face. Another CNA reported that when she and the LPN entered, the resident appeared visibly shaken, frightened, and was shaking, and later stated that the man had held his hand over his mouth and tried to kill him.

Subsequent documentation for this resident included a nursing progress note indicating a head-to-toe assessment that identified a bruise and a 0.5 cm skin tear on the left outer arm, swelling near the left eyebrow, and redness near the right side of the mouth, along with complaints of headache and neck pain. A social service note documented that the resident did not sleep well that night. The resident later reported in an interview that some man had attacked him and that he thought he was going to die. The resident’s care plans documented legal blindness and hearing loss, with interventions to obtain his attention prior to speaking and to maintain his physical safety, but the incident occurred during personal care despite these identified needs.

The second resident involved had dementia, psychotic disorders with delusions and hallucinations, generalized anxiety disorder, osteoarthritis, major depressive disorder, and a documented history of trauma and prior abuse. Her care plan identified her as a survivor of abuse at risk for re-traumatization, with triggers including the sight of a male resident, and directed staff to ensure emotional and physical safety, including providing female caregivers during personal care when possible and explaining care before and during provision. Despite this, she was receiving personal care from a male CNA. During the facility’s investigation into the first resident’s abuse allegation, it was discovered that this same CNA reported using a “tactic move” learned from military experience—a circular arm motion—to break the resident’s grip when she had hold of his wrists, during which he struck the left side of her chin.

Clinical records and staff statements for the second resident documented multiple physical findings temporally associated with the CNA’s care. Nursing notes recorded three loose front teeth on the left side, later confirmed by a dentist who found mobility of teeth and a lost bridge, with referral to an oral surgeon for extractions. Bruising under the chin and on both cheeks, in various stages of healing, was identified and measured, with additional bruises noted on both anterior hands and under the neck. Staff statements indicated that another staff member reported the CNA was responsible for the resident’s missing teeth, describing that the resident did something to him and he moved his arms in a way that caused her teeth to fall out. Other staff reported that the CNA admitted he might have caused the bruising by crossing his arms in front of his chest, possibly hitting her chin with his elbow while trying to avoid being hit, and that he referred to having to “declaw the cat,” which he explained as clipping the resident’s nails. Multiple staff also reported that this CNA was frequently stressed, frustrated, fatigued, and showed signs of burnout, and that some residents were afraid of him, linking him to unusual bruises and unsafe, rushed transfers.