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 as required by federal regulations. The incident involved a mental health technician who, according to multiple interviews and a review of video footage, roughly grabbed a resident by the arm and pulled them out of a chair on the patio. The resident, who had diagnoses including dementia, psychosis, depression, and mobility difficulties, subsequently fell to the floor and was then dragged or escorted to their room by the staff member. The resident sustained bruises and reported pain, though they refused pain medication. The incident was not reported by the staff member involved, and there were no other staff present at the time. The resident's care plan indicated a history of behavioral issues, such as spitting at staff and attempting to hit staff with a shoe, with interventions in place to maintain a safe distance during episodes of aggression. Despite these interventions, the staff member engaged physically with the resident in a manner that was described by facility leadership as rough and unnecessary. The event was witnessed by another resident, who reported it to the unit manager. The unit manager then assessed the resident and found physical injuries consistent with the reported incident. The facility's policy required all employees, volunteers, and contractors to be able to identify and prevent abuse. However, the staff member's actions, as corroborated by interviews with the unit manager, DON, administrator, and a DCF investigator, constituted physical abuse. The incident was verified through internal investigation and review of available video footage, which was later recorded over. The abuse was reported to the appropriate authorities, and the facility confirmed the occurrence of physical abuse following their investigation.
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