Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as required by federal regulations. Specifically, a nurse aide physically abused a resident by hitting them multiple times during care. This incident was witnessed by a nurse, who intervened by stepping between the aide and the resident and then escorting the aide out of the room. The facility's own policies, which define abuse and require staff to treat residents with kindness, respect, and dignity, were not followed in this instance. The resident involved had a history of hypertension, aphasia, and right-sided hemiplegia, and was rarely or never understood according to their most recent assessment. The abuse was reported to facility leadership, and the Director of Nursing confirmed that the allegation of physical abuse was substantiated. This event demonstrates a failure to protect a vulnerable resident from physical harm and to adhere to established protocols for resident safety and rights.
Plan Of Correction
R3 was immediately assessed by CRNP for injury. Wound team to provide ongoing assessments and skin checks. Social services provided emotional support immediately following the incident. Continued emotional support will be provided. A new trauma assessment was completed and Careplan updated. The facility notified the resident's family, DOH, Area Agency on Aging, and Cranberry Township police. All residents were interviewed regarding abuse and neglect. No other concerns were reported. All residents with a BIMS score of 13 or below had a full body skin check to investigate for any signs/symptoms of abuse or neglect. No concerns were identified. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation. The facility will review/revise the onboarding process, including background checks and licensure. The facility will review/revise the orientation process, specifically regarding abuse and neglect education in orientation. All nursing staff will be educated on abuse and neglect. All nursing staff will be educated on Cognitive Deficits and Behaviors. Social Services will interview 10 residents on abuse and neglect weekly x4 weeks, then 10 residents monthly or until substantial compliance has been reached. The DON will interview 5 staff members weekly regarding abuse and neglect x4 weeks then monthly or until substantial compliance has been reached. Results of interviews will be reviewed during QAPI. Any concerns will be reported to leadership for immediate investigation.