Failure to Protect Residents from Physical and Verbal Abuse by Staff and Peers
Penalty
Summary
A resident with an intact mental status and a history of dysphagia and weakness reported to the Director of Nursing (DON) that they were slapped on the arm twice by their midnight nurse during care. The resident stated that the nurse was verbally abusive, refused to allow them to use the bathroom, and called them derogatory names. Another staff member, a Certified Nurse Assistant (CNA), was present during the incident and attempted to intervene but was met with aggression from the nurse and subsequently left the room. The CNA reported the incident to another nurse and contacted the facility administration at the end of their shift. The nurse accused of abuse continued to work the remainder of their shift after the incident. The facility's investigation revealed that the incident occurred during the early morning hours while the resident was experiencing acute illness symptoms. The nurse involved was not immediately removed from resident care and continued working until the end of their shift, despite the abuse allegation being reported to staff. The DON and Nursing Home Administrator (NHA) were informed of the incident later in the morning, and the nurse was suspended only after administrative review. The abuse was substantiated, and the resident expressed feeling unsafe and embarrassed as a result of the incident. In a separate event, another resident with impaired cognition was physically abused by a fellow resident in a common area. The incident was witnessed by a receptionist, who observed one resident approach and slap another in the face. The aggressor admitted to the act and expressed intent to repeat it. The incident was reported to the NHA, and the aggressor was subsequently sent for inpatient psychiatric care. Both incidents demonstrate failures in protecting residents from abuse by staff and peers, as well as lapses in immediate response and reporting protocols.
Plan Of Correction
On mandatory reporting, all staff, including nursing, activities, and ancillary services, were re-educated on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to the Abuse coordinator. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance. Deficient Practice #2: Failure to Protect Resident (R801) from Resident-to-Resident Abuse Element #1: R801 was physically assessed and found to have no visible injuries. Resident was offered and received psychosocial support by Social Services. Resident's safety plan and care plan were updated. Element #2: Review conducted of all residents residing in common areas with a history of aggressive behaviors. Resident R802 was identified and sent for psychiatric evaluation and inpatient treatment on 4/16/2025. All interactions between cognitively impaired residents are being monitored. Element #3: Lobby/common area supervision increased during peak resident usage hours. Behavioral Care Plans reviewed for all residents with cognitive impairment and aggression history. Staff re-educated all staff, including nursing, activities, and ancillary services, on the "Abuse, Neglect, and Exploitation" policy by 4/17/2025 and monitoring of resident interactions. No staff are permitted to work without re-education. Abuse training emphasized staff must ensure immediate removal of alleged abusers from said areas and make immediate notification to Abuse coordinator. Reception staff received 1:1 education on mandatory reporting. The Medical Director was notified of the event and involved in QAPI review. The policy for abuse and neglect was reviewed by the IDT Team and deemed appropriate. Element #4: The Administrator or designee will conduct weekly rounds for four weeks then 1 x a month for 3 months until QAPI determines sustained compliance in communal areas to verify active supervision and implementation of care plan interventions. The IDT Team will hold weekly At-Risk Meetings to monitor residents with high-risk behaviors and review behavior logs. All reported incidents involving potential abuse, elopement risk, or behavioral triggers will be reviewed monthly in QAPI meetings to identify trends and provide ongoing solutions. A monthly audit of care plans for residents with behavioral or cognitive concerns will be conducted to ensure individualized supervision strategies are in place and staff are aware of them. The QAPI committee will review audit results monthly and ensure any issues are corrected. The Facility Administrator will be responsible for maintaining compliance.
Removal Plan
- The DON and designee(s) interviewed/assessed residents with BIMS scores of 8 and above for potential abuse. Residents with BIMS below 8 were assessed by a licensed nurse for an acute change in condition. Concerns were/were not identified.
- Social Services completed a supportive visit with R800.
- LPN E was suspended pending investigation and has not returned to the facility.
- The Abuse, Neglect and Exploitation policy was reviewed by the Administrator and deemed appropriate.
- The Administrator/designee re-educated all staff on the Abuse, Neglect and Exploitation policy, highlighting the requirement to notify the Abuse Coordinator (Administrator) immediately with all abuse allegations. No staff member will be permitted to work until re-education is received.
- The facility Medical Director was notified of this event.
- Facility IDT Team held an ADHOC QAPI meeting.
- From the abuse policy all staff were educated on: Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; Providing emotional support and counseling.
- CENA that left the room was provided 1:1 education regarding not to leave resident alone with abuser and the LPN assigned to the resident was provided 1:1 education to immediately report allegations of abuse and remove abuser as well and the educations received will be added to both their employee files.
- Facility IDT Team conducted an audit on all residents for their Safety/Abuse. Any negative findings will be immediately corrected.
- All findings will be taken to QAPI to follow up/track for any systematic changes that may be needed.