Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident with dementia, restlessness, agitation, and cognitive communication deficits from physical abuse. On the day of the incident, a certified medication technician (CMT) engaged in a verbal altercation with the resident after the resident coughed or pretended to cough on another staff member. The CMT used profanity, called the resident derogatory names, and both parties exchanged threats. The situation escalated when the CMT pushed the resident, who pushed back, leading the CMT to strike the resident around the face and neck, pushing the resident against the wall. Other staff intervened, pulling the resident away, which resulted in the resident falling to the ground. The resident sustained visible injuries to the neck and hand. Multiple staff members were present during the incident, and their accounts varied. Some staff initially wrote statements indicating the resident attacked the CMT, but later interviews and a second statement from one CNA described the CMT as the aggressor, using physical force and continuing to attempt to strike the resident even after the resident was on the ground. The resident reported being assaulted by the CMT and expressed feeling unsafe and distrustful of the staff. Physical evidence of injury was observed and measured by the wound nurse, including scratches on both sides of the neck and on the hand. The facility's abuse policy required immediate protection and investigation of alleged abuse, but the initial response focused on staff statements that framed the resident as the aggressor. The nurse and DON did not specifically ask the resident if they had been assaulted, and the initial staff statements were collected in a group setting, with some staff later reporting feeling coerced to match their accounts. The incident was not immediately reported as abuse, and the resident's allegations and injuries were not promptly or thoroughly investigated according to policy requirements.