Failure to Prevent Staff-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident abuse, resulting in two separate incidents involving physical abuse by staff members. In one case, a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and major depressive disorder was involved in an altercation where a Geriatric Nurse Aide (GNA) struck the resident in the face after the resident had first smacked the aide. The incident was reported to the administrator, and the resident was assessed for pain and injury, with no physical harm noted at the time. The resident did not recall the event and denied pain, but the event was corroborated by other staff who heard the altercation. In another incident, a cognitively intact resident with diagnoses including spinal stenosis, bipolar disorder, and chronic heart failure reported being physically assaulted by a Maintenance Assistant (MA) who was intoxicated while on duty. The MA used profane language, hit the resident on the back of the head, and poked the resident on the shoulder. Another resident witnessed the event and noted the smell of alcohol on the MA's breath. The MA was observed by staff to be intoxicated, refused to leave the facility when directed, and was later reported to have struck the resident. The resident expressed fear of the MA following the incident. Both incidents were documented in the facility's records and confirmed through interviews with staff and residents. The facility's abuse prevention policy prohibits such actions and requires immediate reporting of abuse allegations. Despite these policies, the facility did not maintain an environment free from staff-to-resident abuse, as evidenced by these two events involving physical harm to residents by staff members.