Failure to Prevent Resident Abuse by LPN
Penalty
Summary
The facility failed to protect three residents from physical and/or mental abuse, as evidenced by an incident involving an LPN and three residents. According to facility documentation and staff and resident statements, the LPN was observed in a resident's room wearing full PPE, tapping one resident on the chest and back, and inserting her fingers into the resident's mouth. Blood-stained wash cloths were found on the floor, and two other residents in the room were shouting for help. One nurse aide reported that the LPN prevented her from entering the room and did not report the incident immediately. Resident interviews revealed that the LPN instructed them to put on PPE gowns, restricted their movement, and physically abused one resident by hitting and forcing wash cloths and towels into her mouth. One resident called 911 for help. As a result of the incident, the abused resident was transferred to the emergency room and was found to have petechial hemorrhages on the hard palate, periorbital edema, swollen lips, and difficulty closing her mouth. Nursing documentation noted that the resident expressed fear for her life. The other two residents also reported being frightened and subjected to inappropriate actions by the LPN, such as being sprinkled with water and being prevented from leaving the room. The facility's failure to intervene promptly and ensure the residents' safety resulted in actual physical harm to one resident and mental distress to all three involved.