Failure to Protect Resident from Physical Abuse by LPN
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) physically abused a resident by placing both hands on the resident's neck and pushing them backwards in their wheelchair. This incident was captured on video surveillance and observed by multiple staff members present at the nurse's station. The LPN was seen pointing a finger at the resident's face before the physical contact occurred. The event was not immediately reported by the staff who witnessed or were aware of the altercation. The resident involved had diagnoses including dementia, major depressive disorder, and obesity, but was documented as having full cognition according to a recent mental status assessment. The resident's care plan identified them as at risk for abuse and included interventions such as prompt investigation of all allegations and ensuring a safe environment. However, the care plan was not updated or amended following the incident, and the required reporting procedures were not followed by staff who witnessed or were aware of the abuse. Interviews revealed that staff members who observed or intervened in the incident did not report the abuse to supervisors as required by facility policy. Instead, attention was initially focused on a subsequent incident in which the resident reportedly attacked a staff member. The abuse was only discovered after video review related to the staff injury, indicating a failure in immediate recognition and reporting of abuse as mandated by facility policy and state regulations.