Failure to Protect Resident from Staff-to-Resident Abuse
Penalty
Summary
A cognitively impaired resident with a history of dementia, behavioral symptoms, and the need for substantial assistance with personal care was subjected to staff-to-resident abuse. The incident occurred when a CNA, working alone with the resident during the night shift, responded to the resident's combative behavior by physically restraining her arms using a shirt. This action resulted in dark purple bruises on the resident's bilateral wrists and left hand. The resident later reported the incident to her daughter, describing the staff member's actions and identifying her by physical characteristics. Multiple staff members observed the bruising and heard the resident's allegations, but failed to immediately report the incident as required. The clinical record indicated that the resident was at higher risk for abuse due to her behavioral symptoms, including verbal and physical aggression, and her need for assistance with mobility and personal care. Despite these known risks, the staff member involved did not seek assistance from other staff when the resident became combative, nor did she follow established protocols for managing challenging behaviors. Instead, she attempted to restrain the resident, which is considered abusive according to facility policy. The resident's care plan included interventions for behavioral symptoms, but these were not followed during the incident. Additionally, several staff members, including CNAs and an LPN, became aware of the resident's allegations and observed the resulting injuries but did not immediately report the situation to facility leadership or initiate an investigation. This delay in reporting further compromised the resident's safety and failed to ensure timely protection from abuse. The facility's policy clearly states that any suspicion or allegation of abuse must be reported and investigated immediately, and that staff retaliation or inappropriate handling of resident behaviors constitutes abuse.