Failure to Protect Resident from Abuse by Staff
Penalty
Summary
A resident with severe cognitive impairment, quadriplegia, and anxiety, who was dependent on staff for all activities of daily living, reported to shower aides that an aide had thrown a cup of water in their face after the resident requested ice water during the night. The incident was documented in the facility's initial and final incident reports, which confirmed that the claim was substantiated following an investigation. At the time of the incident, only the resident and two CNAs were present in the room. The facility's policy on abuse, neglect, and exploitation states that protections must be in place to prevent abuse and psychosocial harm to residents. Interviews with staff indicated an understanding that abuse includes not taking care of residents or observing unexplained bruising, and that concerns should be reported to a superior or administrator. Despite these policies and staff awareness, the resident was not protected from abuse, as evidenced by the substantiated incident of a staff member throwing water in the resident's face.