Staff-to-Resident Physical Abuse During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA during incontinence care. The resident had multiple significant medical diagnoses, including severe chronic kidney disease, diabetes, hypertension, deep vein thrombosis, myocardial infarction, history of pulmonary embolism, diabetic retinopathy, delirium, dementia with agitation, pulmonary edema, and spondylosis. An MDS assessment documented severely impaired cognitive skills, and the admission assessment noted the resident had clear speech, was sometimes able to understand instructions, had a pleasant mood, no observed behaviors, was always incontinent of bowel and bladder, had no skin impairments, and ambulated with a walker. Nursing skilled notes in the days immediately prior to the incident documented no voiced complaints and no resistance to care or refusals. On the date of the incident, a change of condition form completed by the primary nurse documented that the nurse witnessed a CNA hit the resident during incontinence care after the resident became aggressive and swung at the CNA, breaking the CNA’s necklace. The form stated that the CNA punched the resident twice in the lower back with her fists. The resident then demonstrated paranoid and aggressive behaviors, refused assistance with changing, refused physical assessment, and ran into the hallway without pants, would not allow anyone to touch her, and sat in a chair in the hall with a sheet over her legs. The nurse practitioner’s note from the same day described the resident as increasingly confused, agitated, and combative, sitting in the hallway soiled in a disposable brief and refusing to allow staff to change her. The NP documented that the resident was unaware of self, surroundings, or location, was attempting to contact her father, and that a thorough review of systems and physical exam could not be completed due to the resident’s mental status. Subsequent documentation showed that after the incident the resident initially refused to speak with social services and was described as agitated, confused, and unwilling to allow staff to assess or change her until a family member arrived. Later nursing notes indicated that the resident calmed, resumed taking medications, and allowed care, with skin assessments revealing no physical injury or pain. Psychiatry later documented the resident’s report that the CNA came from behind, grabbed, and started hitting her, and that she had to defend herself until staff intervened. The facility’s investigation included written statements from the witnessing RN, who reported that the CNA pushed the resident on her side, insisted on finding her broken necklace in the bed or brief despite the resident’s request to stop, and then punched the resident in the thigh/back twice while stating, “I just don’t care anymore.” The CNA’s own written statement acknowledged the resident became combative, broke her necklace and name tag, and that the CNA continued to attempt to provide care despite the resident’s refusals. These events constituted the substantiated incident of staff-to-resident physical and verbal abuse that led to the cited deficiency.
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