Failure to Protect Resident from Physical Abuse by Family Member
Penalty
Summary
A severely cognitively impaired resident, dependent on staff for all activities of daily living and with a history of intellectual disability and neurological condition, was subjected to physical abuse by a family member while in the facility. The family member entered the resident's room and struck her with a belt three to five times, resulting in visible whip-like marks on the resident's left upper thigh and abdomen. Multiple staff members, including a nurse and two nurse aides, heard the sounds of the abuse and the resident's cries of pain but did not immediately intervene or enter the room to stop the incident. The nurse, after hearing the sounds and confirming with the aides, chose to inform the Unit Manager rather than directly intervening, citing shock and the presence of a family member as reasons for her inaction. The nurse aides also heard unusual noises and looked into the resident's room but did not witness the act directly due to a pulled curtain and did not take further action, returning to their duties with other residents. One aide later admitted not knowing that a family member hitting a resident constituted abuse within the facility. The family member later confirmed during an interview that she had hit the resident with a belt to discipline her for undressing, stating she was unaware that this was considered abuse or that it would result in police involvement. The incident was eventually reported to the Unit Manager, who entered the room, observed the family member with a belt, and found the resident with red, raised marks consistent with being struck. The resident was assessed for pain and skin injury, with documentation noting whip-like marks but no ongoing pain or skin breakdown. The event was witnessed and reported by staff, and the police were called to investigate. The resident, due to her cognitive impairment, was unable to express her recollection of the event. The deficiency centers on the failure of staff to immediately protect the resident from abuse by not intervening when the abuse was occurring, despite clear auditory evidence and the presence of multiple staff members nearby.