Failure to Protect Resident from Staff-to-Resident Abuse and Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with diagnoses including schizophrenia, insomnia, and ADHD, who was cognitively intact and required supervision with activities of daily living, was not protected from staff-to-resident abuse. The incident involved the Social Services Director (SSD) and was witnessed by another resident and an activity aide. According to witness statements, the SSD attempted to remove the resident from her office by shoving and pulling the chair out from under the resident, causing the resident to fall to the floor. The activity aide reported this action as abuse and stated that the situation escalated as a result of the SSD's actions. The resident became upset, broke the chair, and subsequently left the facility, leading to police involvement and a hospital transfer. The incident was not immediately reported to the Director of Nursing (DON) or the Administrator, both of whom stated they were unaware of the abuse allegation until informed by surveyors. The activity aide claimed to have reported the incident to the DON on the day it occurred, but the DON denied receiving any such report. The Administrator, who also serves as the abuse coordinator, was only made aware of the resident's behavioral outburst and not the alleged abuse by the SSD. Facility policy defines abuse as the willful infliction of injury or unreasonable confinement, and both the DON and Administrator acknowledged that pulling a chair from under a resident, causing a fall, constitutes abuse. The facility failed to ensure that the resident was protected from abuse and that allegations were promptly reported and investigated according to policy. The care plan for the resident specified that the resident should remain safe and free from mistreatment, and the facility's abuse prevention policy requires protection from abuse by anyone. The lack of timely reporting and investigation of the incident contributed to the deficiency identified by surveyors.