Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff, as identified through observation, interview, and record review. This incident involved one resident out of three reviewed for abuse and resulted in an Immediate Jeopardy situation. The report documents that the facility did not ensure the resident's right to be free from abuse, specifically physical abuse by staff, as required by federal regulations. The deficiency was substantiated by findings from the survey, which included direct evidence of the abuse and the facility's failure to prevent it. No additional details about the resident's medical history or condition at the time of the incident are provided in the report.
Plan Of Correction
F600 - Freedom from Abuse, Neglect, and Exploitation Deficient Practice #1: Failure to Protect Resident (R800) from Staff Abuse Element #1: Resident R800 received immediate emotional support from Social Services on 4/16/2025. Resident was assessed by nursing for physical injury and psychosocial trauma. Ongoing counseling and support have been arranged as requested by resident. Resident's care plan was updated to include Element #2. Element #2: On 4/16/2025, all residents with a BIMS of 8+ were interviewed for abuse concerns. Residents with BIMS <8 were assessed for known history of behavioral challenges, cognitive impairments, or psychiatric diagnoses to determine if any similar incidents or risks were present. No further noncompliance or similar incidents were identified during this audit. Element #3: LPN “E” was immediately suspended on 4/3/2025 and has not returned to the facility. CNA “C” and LPN “D” received 1:1 education.