Failure to Prevent and Thoroughly Investigate Abuse Incidents
Penalty
Summary
The facility failed to protect residents from abuse and to thoroughly investigate an allegation of resident-to-resident abuse. A former resident with intact cognition, dependent on staff for most ADLs, reported that a confused male resident with dementia entered her room, refused to leave when asked, lifted her shirt, grabbed her arm, and slapped her on the forehead. A CNA heard the resident yelling "get out," found the male resident standing over her, removed him from the room, and then returned to check on the former resident, who described the unwanted contact. The Administrator and Charge Nurse later interviewed the former resident, who stated she was unsure what the male resident was doing and was fearful at the time of the incident. Although the incident was reported and the former resident was assessed with no apparent injury, the investigation did not include interviews or assessments of other similarly situated residents to determine whether they had experienced or were fearful of abuse. The facility also failed to protect another resident from staff-to-resident abuse during personal care. This resident had Alzheimer’s disease, severely impaired cognition with a BIMS score of 03, and required dependence or substantial/maximal assistance for bathing and toilet hygiene. Her care plan identified behavior problems and physical aggression during care, with interventions to anticipate and meet her needs and provide positive interaction. During an episode of bathroom assistance, the resident began yelling and became combative, prompting a second CNA to enter and assist. According to the self-reported incident and witness statement, when the resident attempted to bite the assisting CNA, that CNA responded by pushing the resident’s head back while yelling at her to stop, aggressively grabbing her arms, and then grabbing her chin and yelling into her face to stop. The witness CNA reported that the assisting CNA later remarked that adrenaline made her want to do something before leaving the room. These actions occurred despite a facility policy stating that abuse, defined as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, would not be tolerated.
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