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, despite having an abuse prohibition policy and identifying the resident as being at risk for abuse. The resident had Alzheimer’s dementia, diffuse traumatic brain injury, and was severely cognitively impaired, requiring staff assistance for toileting, showering, and personal hygiene. The resident’s care plan documented they were at risk of being a victim of abuse related to aggressive behavior and were to be monitored for safety, including one-to-one supervision after a recent hospital readmission. Nursing notes around the time of the incident documented episodes of agitation, wandering, cursing, and attempts to strike staff and another resident. On the date of the incident, the resident’s representative had a hidden camera in the resident’s room to identify triggers for the resident’s behavior. Video footage from that camera showed the CNA in the resident’s room raising a small black broom and striking the resident on the top of the head, then later grabbing the resident by the neck and roughly placing them into a reclining wheelchair. When the resident used their arms to shove the CNA away, the CNA used their left hand to strike the resident on the left side of the neck. The resident was heard saying “Ouch” and “Ow” multiple times and cursing during the interaction. The CNA then positioned the resident in the wheelchair with it tilted back, preventing the resident from getting up without staff assistance. Facility staff, including an LPN and an RN, viewed the hidden camera footage on the representative’s phone and confirmed seeing the CNA strike the resident on the left side of the neck. Hallway surveillance showed a non-clinical staff member assigned to supervise the resident handing a broom and dustpan to the CNA at the doorway of the resident’s room, though this staff member reported not hearing any commotion or altercation. The resident’s representative and medical provider later stated that, if the resident were cognitively intact, the interaction would be expected to cause fearfulness and agitation. The facility’s internal investigation, based on staff review of the video, concluded that physical contact and abuse did occur, resulting in psychosocial harm to the resident.
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