Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with dementia and hypertension was not protected from physical abuse by a staff member. During evening care, the resident became agitated and combative while being assisted by three nurse aides. According to direct observation by one nurse aide, another nurse aide struck the resident on the left lower arm with an open hand after the resident had hit her. The resident did not respond verbally or physically to being struck, and no injuries were observed during a subsequent assessment. The incident was witnessed by one nurse aide, who did not immediately report the abuse to the on-duty nurse due to fear of confrontation with the involved staff member. Instead, the witness left the facility at the end of her shift and reported the incident to the Director of Nursing after arriving home. Another nurse aide present in the room stated he did not observe the physical abuse but heard the involved aide express frustration toward the resident. The on-duty nurse and Director of Nursing were not made aware of the incident until after the witness had left the facility. The resident's care plan included specific interventions for managing cognitive loss and agitation, such as being patient, breaking tasks into subtasks, and gently redirecting inappropriate actions. Despite these interventions, the staff member's response to the resident's behavior resulted in physical abuse, which was not immediately reported or addressed by those present at the time.