Failure to Prevent Physical Abuse and Follow Care Plan Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during the provision of care. The resident had a history of traumatic brain injury, anxiety, severely impaired cognition, and exhibited verbal and physical aggression toward staff. The resident’s comprehensive care plan required two caregivers for care, specified no male caregivers, and ordered 1:1 supervision during the night shift due to falls. Despite these documented interventions, a male certified nurse aide (CNA) participated in providing incontinence care to the resident during the night shift, and the care was initiated even after the resident verbally refused to be touched. During early morning care, two CNAs, including a male CNA, attempted to change the resident’s incontinence brief. The resident, who was lying naked on the bed, stated they did not want to be touched. One CNA suggested reapproaching later, but the male CNA insisted on proceeding due to time constraints. The resident initially allowed repositioning but began swinging when the brief was being pulled up and stated they did not want the CNAs touching them. The resident then spat in the male CNA’s face, after which the male CNA placed a hand on the resident’s face and forcefully pushed it down. This action was witnessed by the assisting CNA, who observed the resident become red in the face and more agitated. Following the incident, the assisting CNA pushed the male CNA away from the resident and told him to leave the room. A nearby LPN heard the resident screaming and, upon entering the room, was told by the resident that a CNA had yelled at and disrespected them and had scratched their face twice. Assessment by the RN/Assistant DON later that day revealed multiple abrasions and areas of redness on the resident’s face, including below the right eye and cheek, the tip of the nose, the left eyebrow and below the left eye, and around the lips and chin. The resident appeared agitated and reported being scratched in the face. The incident was reported up the chain of command, but there was no documented evidence that the male CNA was immediately removed from the premises after clocking out, and facility leadership could not confirm that the CNA had actually left the building at that time.
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