Failure to Protect Residents from Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving harm to residents. In the first incident, a cognitively intact resident who was totally dependent on staff for all activities of daily living, including transfers and personal care, was physically assaulted by a CNA. The resident reported being punched twice in the face by the CNA after a verbal exchange regarding a snack. The resident sustained a 2.5 cm laceration to the left face, requiring four stitches, and a contusion to the left orbital area. The injury was discovered by morning staff, and the resident continued to experience significant pain when eating and drinking following the incident. Facility video surveillance confirmed the CNA's presence in the resident's room multiple times during the relevant time frame, and interviews with staff and the resident corroborated the account of physical abuse. In the second incident, a moderately cognitively impaired resident was injured by another resident with severe cognitive impairment. The event occurred in the facility's smoking area, where the aggressor struck the victim on the forehead with a hand grabber following a dispute over cigarette butts. The injured resident sustained a 1.5 cm laceration to the left scalp, which required staples. The incident was witnessed by the DON, who immediately separated the residents and observed blood oozing from the victim's forehead. The aggressor was subsequently sent for behavioral evaluation, and the injured resident was sent to the emergency room for treatment. Both incidents demonstrate a failure by the facility to ensure residents' right to be free from physical abuse, as required by policy and regulation. The first incident involved staff-to-resident abuse resulting in actual physical harm, while the second involved resident-to-resident abuse with injury. In both cases, the residents required emergency medical attention for their injuries, and the facility's policies for abuse recognition and reporting were referenced in the investigation.