Failure to Protect a Cognitively Impaired Resident From Physical and Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA. The resident had dementia with severe cognitive impairment, as evidenced by a BIMS score of 3/15, and was not reliably interviewable. On the date of the incident, the resident was in her room, agitated and mumbling, when a new LPN entered to assist a CNA with transferring the resident to bed using a mechanical lift. According to the LPN’s account, the CNA tapped or hit the resident on the head while the resident was mumbling, and the resident reacted by saying she would report him. The LPN reported that after the head strike, the CNA retrieved the resident’s communication whiteboard and wrote that the LPN was there to help, but the resident remained agitated and raised her hands. The LPN stated that the CNA then got in the resident’s face, taunted her, grabbed her hands, and pushed them down. The resident reportedly told the CNA she would report him to the state, and the CNA allegedly laughed and responded that nobody cared about her. The LPN described feeling very uncomfortable with the CNA’s aggressive treatment and remained with the resident afterward because the resident was upset, afraid, and stated she did not like being hit on the head. In his written and verbal statements, the CNA admitted to hitting or tapping the resident on the head to get her attention, acknowledging he could have chosen to tap her shoulder or arm instead. He confirmed that the resident said she would report him, though he denied verbally responding to that statement. The facility’s abuse policy defines physical abuse as including hitting and slapping, and verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged the CNA’s physical contact with the resident’s head but offered no explanation for it and stated he was not aware of any verbal abuse allegation. There was no past non-compliance document related to this incident in the facility’s records, despite the reported physical and verbal interactions described by the LPN and partially acknowledged by the CNA.
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