Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse. The incident involved a mental health technician who, according to multiple interviews and a now-overwritten video recording, engaged in rough physical handling of a resident on the facility's patio. The resident, who had diagnoses including dementia, psychosis, depression, and a history of falls, was moderately cognitively impaired but independent in activities of daily living. During the incident, the staff member pulled the resident out of a chair, and after a series of escalating interactions, the resident fell to the floor and was subsequently dragged or escorted to their room by the staff member. The resident sustained physical injuries, including bruises on the left knee and right forearm, and reported pain in the left knee. A physical assessment was performed, and the resident was found to be upset and yelling after the incident. The event was initially reported by another resident to the unit manager, who then assessed the resident and escalated the report to facility leadership. The incident was corroborated by interviews with the unit manager, DON, administrator, and social services director, all of whom reviewed the available evidence and confirmed the staff member's actions as physical abuse. The facility's own policies require staff to be able to identify and prevent abuse, but in this case, the staff member's actions were not reported by the perpetrator and only came to light through a third-party report. The incident was verified through internal investigation and interviews, and the staff member involved was found to have acted in a manner that was rough and unnecessary, resulting in physical harm to the resident.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/ N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and appropriate actions will be taken as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and any appropriate actions will be implemented as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025