Failure to Protect Resident from Staff Abuse
Penalty
Summary
A resident with moderate cognitive impairment, a history of dementia, Parkinson's disease, and behavioral disturbances experienced an incident involving physical and mental abuse by staff. The resident, who was hard of hearing and used both a walker and wheelchair, exhibited agitation, aggression, and confusion, including swinging objects at staff. During the incident, staff failed to de-escalate the situation and instead engaged in unprofessional conduct, including swearing at the resident, taunting, and physically restraining the resident inappropriately. One staff member threw a blanket over the resident's head and forcefully grabbed objects from the resident, while another staff member used a pressure point technique and verbally threatened the resident with statements such as "you're going to jail" and derogatory language. Multiple staff statements and witness interviews confirmed that the staff involved did not follow appropriate de-escalation techniques and instead antagonized the resident, escalating the situation further. The resident was left feeling abused, as evidenced by statements made during and after the incident, and was observed to be in significant distress. Documentation and interviews indicated that the staff's actions were not in accordance with the resident's care plan, which included specific interventions for managing behavioral symptoms and ensuring the resident's safety and dignity. The incident resulted in the substantiation of abuse against the involved staff members, who were subsequently suspended and terminated. The resident was evaluated by emergency medical services and transferred to the hospital for further assessment. The deficiency was identified through observation, interviews, and document review, which revealed that the facility failed to protect the resident from mental and physical abuse by staff, as required by regulatory standards.