Failure to Prevent and Investigate Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to prevent staff-to-resident physical abuse involving a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD. The resident, who was cognitively intact but exhibited disorganized thinking and was frequently incontinent, became agitated after being told by an LPN that she could not go outside to smoke outside of scheduled times. The situation escalated when the resident threw water on the LPN, and according to multiple staff interviews, the LPN retaliated by throwing ice water back on the resident, soaking her gown. The incident resulted in the resident calling the police and expressing distress over the nurse's actions. The facility's investigation into the incident was incomplete and lacked thorough documentation. The Regional Director of Operations was unable to provide a comprehensive investigation, and only a few resident and staff statements were available. Interviews with staff and the resident confirmed that the LPN had thrown water on the resident in response to the resident's actions. The facility's policy required immediate removal of staff accused of abuse pending investigation, but the LPN was allowed to finish her shift after the incident, and the allegation was not reported in a timely manner. The facility's policy on abuse, neglect, and exploitation outlined specific steps for investigating allegations, including immediate suspension of accused staff and thorough interviews with all potential witnesses. However, these procedures were not followed, as evidenced by the incomplete investigation and the LPN's continued presence in the facility after the incident. The failure to promptly and thoroughly investigate the allegation and to remove the accused staff member from duty contributed to the deficiency.