Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of Alzheimer's disease, who was dependent on staff for all activities of daily living and had a history of repeated falls, was not protected from physical and verbal abuse by a staff member. The incident occurred when the resident repeatedly attempted to get up from their wheelchair during an evening meal service. An LPN became increasingly aggravated, raised their voice, and demanded the resident to sit down. The LPN was observed by staff to push the resident back into the wheelchair after the resident attempted to get up. The LPN's actions were loud enough to draw the attention of other staff, and the incident was witnessed by a dietary manager who intervened by removing the resident from the situation. The facility's policy stated a commitment to an abuse-free environment and outlined measures to prevent abuse, including supporting staff in managing frustration and stress. Despite these policies, the staff member's conduct constituted both physical and verbal abuse, as the resident was subjected to being pushed and spoken to in a demanding manner. The incident was reported to the DON, and an investigation was initiated. The resident's family was notified, but the deficiency centers on the failure to prevent the abusive behavior from occurring.