Failure to Protect Resident from Physical Abuse by Staff Member
Penalty
Summary
A facility failed to protect a resident's right to be free from physical abuse by a staff member. The incident involved a resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who required assistance with most activities of daily living and had an intact mental status as indicated by a BIMS score of 14. The resident reported that during the early morning hours, while receiving incontinence care from an assigned nurse, she accidentally kicked the nurse out of fear of falling. In response, the nurse allegedly hit the resident on the left upper arm and told her she would have to wait for the day shift to finish her care. The facility's investigation included interviews with both the resident and the nurse involved. The resident consistently reported the incident, stating she felt safe in the facility otherwise and requested not to have the same nurse assigned to her in the future. The nurse denied the allegations, claiming she did not provide any ADL care to the resident during her shift and only interacted with her for medication administration. The nurse also stated the resident was confused and denied any physical contact or awareness of abuse during her shift. Despite the nurse's denial, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse had violated work rules related to confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward a resident. The nurse continued to work in the facility after the incident, and the disciplinary action document reflected the substantiated abuse and neglect.
Plan Of Correction
F600 Free from Abuse and Neglect It is the intent of the facility to ensure that all alleged violations are thoroughly investigated to prevent further potential abuse. Element 1: Resident 404 does not reside within the facility. Nurse M is no longer working at the facility. Facility staff were re-educated on Abuse Policy. Element 2: All residents residing in the facility can be affected by the cited practice. Residents with BIMS score of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the facility managers were educated on disciplinary actions and the administrator and DON educated with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 4: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.