F0600

G

Failure to Protect Resident From Repeated Verbal and Physical Abuse by CNA

Philadelphia, Pennsylvania Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident from staff-to-resident physical abuse. The resident had diagnoses including heart failure, muscle weakness, major depressive disorder, and an above-knee amputation of the left leg, and was admitted with these conditions. The facility’s abuse policy stated that the facility prohibits mistreatment, neglect, and abuse of residents, and that staff must be trained, in control of their behavior, and able to respond appropriately to resident behavior. Despite this policy, the resident reported being verbally, physically, and mentally abused by a CNA, identified as Employee E4.

On one occasion, the resident and CNA E4 had a verbal altercation at the nurses’ station. A nurse aide witness, Employee E6, observed CNA E4 and the resident engaged in a loud back-and-forth argument, with CNA E4 repeatedly speaking to the resident in Spanish, which caused the resident to become increasingly agitated. Employee E6 did not understand the Spanish language content but heard CNA E4 say in English, “I won’t open the door!” Both the resident and CNA E4 were speaking in raised voices. To calm the resident, Employee E6 assisted the resident in signing the logbook to leave the locked unit and opened the door. Employee E6 then reported the incident to the Nursing Supervisor, Employee E8, after the supervisor had already heard the raised voices from the office. This verbal abuse incident was later substantiated by the facility during the investigation of a subsequent event.

On a later date, a second, more serious incident occurred between the same resident and CNA E4. The resident approached the ADON, Employee E3, and complained that CNA E4 would not open the door or do anything for the resident. As the resident began to wheel away, CNA E4 said something in Spanish that caused the resident to become suddenly very agitated and propel toward CNA E4. ADON E3 instructed CNA E4 to move away, but CNA E4 refused, stating, “I will not move!” When the resident reached CNA E4, the resident grabbed CNA E4’s sweater collar. ADON E3 removed the resident’s hands from the collar, at which point CNA E4 placed a hand around the resident’s neck in a choke-hold position. ADON E3 called for help while attempting to pry CNA E4’s hand from the resident’s neck. After E3 removed that hand, CNA E4 placed the other hand on the resident’s face and pushed it, and E3 again had to remove the CNA’s hand and redirect the resident’s wheelchair away. The facility’s investigation documented that CNA E4 placed the resident in a choke-hold and put a hand on the resident’s face, and that this was staff-to-resident abuse. The report concluded that a reasonable person would determine that holding a resident with major depression and heart failure in a choking hold caused actual harm and placed the resident at risk for psychological trauma.

The investigation also revealed that the earlier verbal abuse incident involving CNA E4 and the same resident had not been reported in a timely manner to the DON or the Nursing Home Administrator. The DON stated she was unaware of the first incident until she investigated the second incident, and confirmed that both incidents were reported to the State Survey Agency together at a later date. A staff member reported that she had witnessed the earlier event but did not initially recognize it as abuse until after an in-service training where examples of abuse were presented. The facility’s own documentation noted that this was not the first time CNA E4 had been suspended or suspected for abuse. The combination of the substantiated verbal abuse and the subsequent physical altercation, in which the CNA’s hands had to be pried from the resident’s neck and face, demonstrated that the facility failed to ensure the resident was free from physical abuse as required by its policies and state regulations.