Failure to Protect Residents from Abuse by Visitors
Penalty
Summary
The facility failed to protect residents from abuse by visitors, resulting in two separate incidents involving physical abuse by family members during visits. In the first incident, a resident with heart failure and anxiety disorder, who was cognitively intact and required moderate assistance for transfers, was subjected to physical abuse by her spouse, who has dementia. The spouse was observed by multiple staff members pinching, twisting, and shoving the resident while she was in her wheelchair, causing pain, bruising, and distress. The incident occurred after a verbal argument and was witnessed by several staff, who intervened to separate the resident from the family member. The resident reported pain and bruising to her right shoulder and forearm, and was evaluated for anxiety following the event. In the second incident, another cognitively intact resident with osteoporosis and impaired upper extremity mobility was physically abused by a visiting family member during a disagreement over a phone passcode. The family member grabbed and pinched the resident's right arm, resulting in pain and a circular bruise near the inner elbow. The incident was reported by a nurse who responded to yelling and found the resident upset and injured. The resident confirmed the abuse and stated it was the first occurrence of such behavior from the family member. The nurse did not witness the physical act but observed the aftermath and reported the incident to the DON. In both cases, the facility identified the root cause as inadequate background screening of visiting family members. The incidents were considered unusual as they involved visitors rather than staff. Both residents were asked during admission about any history of trauma or abuse from family members and had denied such history. The facility's policies and procedures for abuse were in place, but the events occurred despite these measures, and the facility had limited authority to screen visitors prior to entry.