State Findings:
Based on observation, record review, review of the facility Abuse and Neglect Prohibition Policy (revised 7/2018) and resident and staff interview, the facility failed to ensure that two (2) residents (R) (R#1 and R#2) were protected from abuse by a Resident Care Specialist (RCS/Certified Nursing Assistant (CNA). Furthermore, another RCS/CNA failed to notify supervisory staff immediately of an observation of the physical abuse, resulting in actual harm, of two residents (R) (R)#1 and R#2, on 9/25/19, by the RCS/CNA perpetrator. This failure to immediately report an observation of the physical abuse and harm of R#1 resulted in the subsequent physical abuse and harm of R#2, on 9/25/19, by the same RCS/CNA perpetrator. The sample size was 21 residents.
Review of the Facility Incident Report Form for R#1 dated 9/25/19 revealed that on 9/25/19 at 9:30 p.m., RCS/CNA AA had pulled on resident #1’s upper body and the resident hit his head on the dresser next to his bed, three times. He sustained a cut on the inside of his mouth. Continued review revealed that RCS/CNA AA also hit R#1 on his upper arm.
Review of the care plan for R#1 revealed that it was revised on 10/7/19 to address his behaviors of jerking and pulling with an intervention for staff to explain all procedures to him before initiating care and allow him time to adjust to changes. If his behavior continues, STOP and come back later. When he has behaviors of pulling and jerking, he will stop if you ask him to.
Review of the Facility Incident Report Form for R#2 dated 9/25/19 revealed that on 9/25/19 at 9:45 p.m., RCS/CNA AA was observed by another RCS/CNA to grab the genitals of R#2 causing him to scream and cry. Continued review of both Incident Reports revealed that RCS/CNA AA was suspended and immediately walked out of the building. Both residents were assessed for injuries. Local Law Enforcement and the State Survey Agency (SSA) were notified of the abuse within the mandated two hours. The Responsible Parties (RP) and Physician were notified.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
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Personal Note from NHA-Advocates
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.
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