F0600

D

Failure to Protect Cognitively Impaired Hospice Resident From Physical Abuse by CNA

North Canton, Ohio Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from physical abuse. The resident had diagnoses including neurocognitive disorder with Lewy Bodies dementia, generalized anxiety disorder, and late-onset Alzheimer’s disease, and was receiving hospice services. An admission MDS showed severe cognitive impairment and a need for maximum assistance with toileting hygiene, and the care plan documented self-care deficits and functional decline requiring staff assistance with ADLs. On the evening of the incident, a nursing progress note documented that a skin sweep revealed no areas of concern, no signs of pain or distress, and that the resident was resting in bed, with no indication that the family had reported abuse or provided an in-room video at that time.

Video surveillance from the resident’s room on the date of the incident showed multiple interactions between the resident and a CNA. In one video, the CNA entered the room and kicked the right side of the resident’s mattress twice with her right foot, causing the resident’s legs to lift up and down with each kick, then removed the covers without speaking. The resident stated, “You don’t like me,” to which the CNA replied, “Yes, I do,” and then walked toward the bathroom door; when the resident repeated, “No, you don’t like me,” the CNA did not respond. In another video, the CNA entered, pulled back the covers, and tapped the resident’s left leg with a gloved fist without appearing to speak, while the resident’s hands were up as if in confusion, and the CNA left the room without further interaction, leaving the resident appearing confused.

A third video showed the CNA providing incontinence care. During this care, the resident repeatedly expressed gratitude and positive comments such as “Thank you,” “I like you a lot,” and “You’re so good at what you do,” without receiving any verbal response from the CNA. Later in the same video, the CNA told the resident to stand up; as the resident moved toward the edge of the bed and asked for clarification, the CNA, walking toward the bathroom, told her in a loud and aggressive tone to “Hold on, hold on.” When the resident attempted to get out of bed and placed her leg on the wheelchair seat, the CNA told her “No, sit down” and then ordered her in a loud aggressive manner to “Sit back.”

A police report documented that the family reported seeing, via an in-room camera, the CNA appear to strike the resident’s leg with her hand and, in a second video, appear to either kick the resident’s leg twice or kick the mattress more forcefully than the hand strike. The police officer viewed the videos, spoke with the CNA, and noted the CNA denied striking the resident, stating she had used the bed frame to scratch an itchy foot while wearing gloves and that she did not lose her temper or patience. The facility’s self-reported investigation described the CNA contacting the bed frame with her foot in a non-aggressive manner and touching the resident’s leg as a cue during care, and concluded the allegation as unsubstantiated. However, interviews with facility staff, including an LPN and an RN coordinator who viewed the videos, described the CNA’s actions as an aggressive slap to the leg and a purposeful kick to the bed, and indicated they did not feel the CNA’s care was appropriate.

Additional documentation showed that a skin assessment the day after the incident identified a skin tear to the resident’s left pinky toe, later documented as a scratch to the right foot pinky toe with treatment ordered and then discontinued when healed. Interviews revealed that another CNA working on the unit was not asked for a witness statement, the resident was unable to provide information due to severe cognitive impairment, and the social worker reported the resident was not provided psych services following the incident. The hospice RN stated hospice was not notified of the abuse allegation, and the medical director did not recall being notified. The facility’s abuse, neglect, exploitation, and misappropriation policy required investigation of all alleged violations and immediate reporting to the administrator and, when a crime is suspected, to law enforcement. The surveyors determined that the facility failed to ensure the resident was free from physical abuse based on the observed actions on video and corroborating staff interviews.