Failure to Protect Resident from Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, borderline personality disorder, and mild intellectual disabilities was not protected from staff-to-resident physical abuse. The resident, who was cognitively intact and required supervision for personal care, became involved in an altercation with a certified nurse aide (CNA) after attempting to move another resident in a wheelchair. The CNA shouted at the resident, leading to a verbal argument that escalated into a physical confrontation in the hallway. Multiple witness statements and a police report indicated that the CNA approached the resident, engaged in a face-to-face confrontation, and initiated physical contact by belly bumping the resident, which led to a fight and the resident being pushed to the ground and hitting her head. The incident was witnessed by another CNA and an LPN, who confirmed that the CNA and the resident exchanged insults and that the CNA was the aggressor in the situation. The police were called, and the CNA was arrested for assault. The resident was assessed for injuries and transported to the hospital, where a CT scan revealed no abnormal findings, and she was discharged back to the facility. The facility's investigation included reviewing statements from involved staff and the resident, as well as the police report, which corroborated that the CNA initiated the physical altercation. The facility's policy defined abuse as willful injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions of the CNA were found to be in violation of this policy. The root cause was identified as a failure to appropriately deescalate and manage resident behaviors, leading to the escalation and subsequent physical abuse of the resident by staff.