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F0600
J

Failure to Protect Resident from Staff Abuse

Tulsa, Oklahoma Survey Completed on 04-04-2025

Penalty

Fine: $84,765
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from verbal and physical abuse by a staff member. During a breakfast pass, a CNA engaged in a heated verbal and physical altercation with a resident in the hallway. The CNA was observed yelling, threatening, and ultimately throwing both a glass of milk and a nearly full gallon of milk at the resident. The incident was witnessed by a CMA and an LPN, who attempted to intervene and de-escalate the situation but were unsuccessful. The CNA continued to act aggressively, including pushing the CMA away and swinging at the resident after slipping and falling. The resident involved had a medical history that included unspecified dementia and schizoaffective disorder, bipolar type. Following the altercation, the resident was found to have a scratch on their forehead, and their glasses were found on the floor with the nose piece stuck in their hair. The incident was captured on facility video surveillance, which confirmed the sequence of aggressive actions by the CNA and the unsuccessful attempts by other staff to protect the resident. The facility's abuse and neglect policy strictly prohibits any kind of abuse against residents. However, after the incident, it was noted that the DON did not provide education on abuse to staff, and the administrator did not come to the facility on the day of the incident. The event was reported to the Oklahoma State Department of Health, and the resident was sent to the hospital for evaluation. The deficiency was identified as the facility's failure to ensure residents were free from abuse.

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