Failure to Protect Resident From Physical Abuse by CNA During Behavioral Outburst
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff when a CNA threw an object at the resident during a behavioral outburst. According to progress notes, the resident, who had intact cognition and diagnoses including gunshot wound to the face and lower jaw, major depression, conversion disorder with seizures, dysphagia, and a gastrostomy, was involved in an incident where they were observed looking through their roommate’s personal items. When confronted, the resident became angry and pushed an LPN on the shoulder, telling the nurse to mind their own business. Later, as staff attempted to redirect the resident back to their room, the resident began swiping items off the nursing desk and throwing several full cups of water at multiple staff members, including the CNA. During this episode, a witness (another CNA) reported that after being struck by two full cups of ice water, the CNA immediately picked up a large insulated cup and threw it at the resident, striking the resident’s hand/wrist area. The resident later referenced having a blood clot in their arm but declined to further discuss the incident. The DON stated that the resident had been angry after being accused of going through the roommate’s belongings while assisting the roommate in finding a remote control and described staff’s catastrophic reactions to resident behavior as unacceptable. Attempts by surveyors to contact the CNA and LPN involved were unsuccessful by the time of survey exit. The facility’s abuse policy stated that residents will be protected from abuse, neglect, and harm and that no abuse or harm of any type will be tolerated.
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