F0600

G

Physical abuse and unsafe transfer of a cognitively impaired resident by CNA

Shreveport, Louisiana Survey Completed on 03-16-2026

Penalty

Fine: $12,735

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse and psychosocial harm by a CNA. The resident, who resided on a locked memory care unit, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer’s disease, and muscle weakness. A quarterly MDS showed a BIMS score of 0, indicating severely impaired cognition, and the resident was dependent on staff for bed-to-chair transfers. The resident’s care plan identified her as a fall risk and required the use of a gait belt for all transfers with assistance from one staff member.

On the morning of the incident, surveillance video with audio captured the events in the resident’s room. The video showed housekeeping staff initially conversing with the resident, who was seated on the side of the bed, smiling, laughing, and verbally interacting appropriately. After housekeeping exited, the CNA entered the room carrying linens and clothing, did not greet or acknowledge the resident, and failed to respond when the resident asked about getting something to eat. The CNA then approached the resident and, without using a gait belt, attempted to pull the resident up by her left arm. The CNA yelled “Get up!” and forcefully gripped and pulled the resident’s left upper arm multiple times in an upward motion. The resident was observed grimacing, saying “Wait,” and being unable to stand, while the CNA continued to hold and manipulate the resident’s left upper arm, swinging her back into the bed when she could not maintain a standing position.

The video further showed the CNA dropping linens and clothing on the bed, forcefully tossing the resident’s shoes to the floor, and ramming the resident’s wheelchair into the wooden footboard, causing the bed to shake. When the CNA brought the wheelchair to the resident, the resident recoiled, appeared frightened, and verbally stated she could get up if the CNA did not mind, but the CNA did not respond. The CNA placed the unlocked wheelchair in front of the resident, lifted the resident by her underarms without a gait belt, and dropped her into the wheelchair, with an audible impact and the resident exclaiming “Ow!” The resident then rubbed her left arm, moaned, and appeared to express pain. The CNA proceeded to pull the resident backward in the wheelchair, again striking the footboard, and then rolled the resident into an unlit bathroom. Throughout the interaction, the CNA repeatedly yelled at the resident by her first name to “Get up,” handled her roughly, and failed to use safe transfer techniques.

Subsequent documentation and interviews linked physical findings to this event. A late entry progress note by the Administrator described a nickel-sized irregular bright purple purpura on the lateral upper left arm near the antecubital space, and a later note documented multiple areas of bright purple purpura on the posterior left upper arm. A weekly skin review by an LPN on 01/11/2026 recorded four small reddish-purple areas on the back of the left upper arm just above the elbow, which the LPN described as looking like fingerprints; the DON reported these could have been from the CNA’s fingerprints. The Administrator and DON both confirmed, based on review of the video, that the CNA physically abused the resident by yelling, grabbing, lifting, twisting, and roughly transferring her without a gait belt, and that the resident appeared frightened during the event. The Administrator further stated that a reasonable person subjected to this physical abuse and verbal aggression would have experienced physical abuse and psychosocial harm, including dehumanization and humiliation.