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F0600
G

Failure to Protect Resident from Physical and Verbal Abuse by Security Guard

Los Angeles, California Survey Completed on 06-23-2025

Penalty

No penalty information released
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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

A deficiency occurred when a resident with dementia and multiple comorbidities was subjected to physical and verbal abuse by a facility security guard. The resident, who was not competent to understand his medical condition and used a wheelchair, became irritable after being redirected away from a restricted area. During this episode, the security guard argued with the resident, cursed at him, and struck him on the back of the head with an open palm, as witnessed by a CNA. The incident caused the resident pain, embarrassment, and resulted in a transfer to a general acute care hospital for evaluation. The facility failed to ensure that the security guard had received required abuse prevention training prior to working in the resident care area. The security guard reported not having received abuse training and only signing paperwork upon hire. The DON stated that abuse training was mandatory for all staff, including those working in resident care areas, and acknowledged that verification of the security guard's training had not been completed. The facility's policy required orientation and abuse prevention training for all staff, but this was not followed in the case of the security guard. Documentation and interviews confirmed that the resident experienced significant pain and emotional distress following the incident. The resident reported a pain level of 8 out of 10 and expressed feeling embarrassed. Progress notes and interviews indicated that the resident did not receive pain relief medication for his head injury. The facility's failure to ensure proper staff training and to protect the resident from abuse directly led to the incident and the resulting harm.

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