Failure to Protect a Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident had vascular dementia with agitation, was severely cognitively impaired, but was usually understood and usually understood others. The resident was generally pleasant, mostly independent with walking, dressing, toileting, and hygiene, and typically got up, dressed, and went to the dining/day area each morning. The resident resided on the special care unit (SCU) for safety and had no documented recent behavioral issues, aggression, falls, or injuries prior to the incident. The resident’s care plan included ensuring areas were free of hazards, redirecting the resident when entering unsafe areas, and preventing serious injuries related to memory/recall deficits. On the morning of the incident, video surveillance from the SCU hallway showed the CNA and the resident at the resident’s doorway. The CNA initially grabbed the resident’s right forearm while the resident stood in the doorway and the resident pulled away. Over several minutes, the resident and CNA appeared to gesture back and forth, with the resident pointing toward the day area and the CNA pointing toward the resident’s room. The video then showed the resident raising his or her arms in front of the CNA, the CNA knocking the resident’s arms down, then holding the resident’s forearms and pushing the resident back into the room. The CNA exited, closed the door, and walked toward the day area. The resident reopened the door and stood in the doorway again, at which point the CNA walked quickly back, grabbed the resident’s forearms, and again appeared to forcefully push the resident into the room while holding the resident’s forearms. A CNA who arrived on the unit around that time reported hearing the CNA repeatedly yell at the resident to get back in bed, while the resident yelled that he or she did not want to go back to bed. This CNA stated that upon looking into the room, the CNA had hands on the resident’s forearms and was struggling with the resident, who was trying to get loose, while the CNA continued to hold and push the resident toward the bed. The CNA told the staff member to leave the resident alone and then to leave the SCU. Another CNA reported that shortly afterward, the resident exited the room visibly upset, loudly stating that the person who had done this needed to be arrested, and pointed to a bleeding area on the forearm. This CNA and others described the resident as very upset and angry, and it reportedly took about two hours to calm the resident. Subsequent assessments documented multiple bruises on both of the resident’s hands and forearms in various sizes and shapes, including circular, linear, oblong, and rectangular bruises, as well as a scabbed area. Nursing staff and the DON observed these bruises and described them as appearing consistent with someone having grabbed the resident. Staff who knew the resident stated that the resident did not usually bump into things, was not clumsy, and had no recent falls. The resident’s physician stated that multiple bruises on the arms and hands would not be expected unless the resident was on many blood thinners, and that the only acceptable reason to grab a resident’s arms would be to prevent a fall or injury. The Administrator later confirmed that review of the video showed the CNA grabbing the resident by the arms and pushing the resident back into the room on two occasions, and that the resident’s responsible party reported bruises and an allegation that the CNA had abused the resident.
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