Failure to Protect Resident from Physical Abuse and Inadequate Incident Reporting
Penalty
Summary
A staff member, identified as an activity aide/CNA, physically intervened with a resident who was seeking to smoke after refusing a blood draw. The staff member confronted the resident, grabbed him by both arms, took him down to the floor, and held him there. The resident, who has muscle wasting, atrophy, anxiety, and a right ankle contracture, subsequently complained of pain and was observed with an abrasion on his right elbow. He was later sent to the hospital and diagnosed with acute bilateral lower back pain, elbow pain, and thumb pain. The resident reported feeling scared and humiliated by the incident. Multiple staff members, including security and nursing staff, were present or nearby during the incident but did not intervene or respond appropriately to protect the resident or gather information for reporting. The activity aide/CNA did not follow proper Crisis Prevention Intervention (CPI) protocols, as confirmed by the social service director and activity director, and failed to report the incident to the appropriate supervisory staff. The nurse and other staff who were aware of the commotion did not document or escalate the event as required by facility policy. The facility's abuse prevention policy prohibits abuse, neglect, and mistreatment of residents and requires all incidents to be documented and reported. However, the incident was not promptly or properly reported to the administrator, DON, or other relevant authorities. The lack of immediate assessment and documentation, as well as the failure to remove the alleged perpetrator from duty, contributed to the deficiency in protecting the resident from abuse and ensuring a safe environment.