Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member and another resident. One incident involved a CNA physically abusing a resident with severe cognitive impairment by slapping her on the left cheek with an open hand and pointing at her aggressively. The resident, who had diagnoses including colon cancer, hemiplegia, vascular dementia, and adjustment disorder, was dependent on staff for activities of daily living and had a BIMS score indicating severe cognitive impairment. The abuse was confirmed through video evidence and staff interviews, with the CNA admitting to the act during an interview. The incident was reported by another CNA, and the resident was observed to be yelling and distressed immediately after the event. A second incident involved resident-to-resident abuse, where another resident with severe cognitive impairment and a history of behavioral disturbances struck the same resident three times in the arm with a closed fist. This altercation occurred at the nurse's station and was witnessed by an LVN. The aggressor resident had a history of dementia with behavioral disturbance, diabetes, and other significant medical conditions. The behavior was noted to be outside her baseline, and it was later determined that she had a urinary tract infection and elevated ammonia levels, which may have contributed to the aggression. Both residents were assessed after the incident, and no visible injuries were noted. The facility's care plans for both residents included interventions for managing unwanted behaviors and cognitive impairment, but these interventions did not prevent the incidents of abuse. Staff interviews indicated that some residents were unaware of their rights or how to report abuse prior to the incidents. The events placed residents at risk of abuse and mental anguish caused by fear, as directly observed and documented by surveyors.