Failure to Protect Cognitively Impaired Resident From Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident was an elderly male with dementia, anxiety disorder, and Alzheimer’s disease, admitted in February and assessed as severely cognitively impaired with a BIMS score of 3.0 and rarely/never understood. His care plan identified impaired cognition and risk for further decline and injury. Despite these vulnerabilities, the resident was subjected to alleged physical abuse during care provision by a CNA. According to a written statement from another CNA who was present, the incident occurred when the two CNAs attempted to provide incontinence care and the resident refused. After the resident refused care multiple times, the reporting CNA began to leave the room, at which point the other CNA allegedly tried to force the resident onto the bed. The resident became somewhat aggressive, and the CNA allegedly responded by manhandling him, forcing him into the bed, and, when the resident tried to push him away, hitting the resident on the arms approximately three to four times with a closed fist. The CNA then allegedly pinned both of the resident’s hands down, forcibly pulled down his shorts, and ripped off his brief, leaving him lying on the bed with his bottom uncovered. The reporting CNA stated she repeatedly told the other CNA to leave the resident alone and to report the situation, but he refused. When the CNA realized the resident would not allow him to complete the change, he allowed the resident to get up and walk out of the room with no clothing on his lower body. The reporting CNA attempted to stop the resident from leaving the room without pants, but the resident did not allow her to do so. The resident was later assessed multiple times with no skin injuries noted, and he was unable to recall any issues with staff during interview attempts. The alleged perpetrating CNA denied being rough or abusive, while the reporting CNA confirmed her written account during a subsequent phone interview. The resident’s family member later stated she filed charges against the CNA and described being extremely upset and traumatized by the incident.
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