Abuse During Medication Administration and Failure to Protect Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease was subjected to physical and mental abuse by an LPN during medication administration. The LPN placed his hand and a paper towel over the resident's mouth and pinched the resident's nose to force the resident to swallow medication, while telling the resident to take the medication. This act was witnessed by a CNA, who observed the resident's face turning red and the resident struggling and moving their head from side to side. The CNA left the room, leaving the resident alone with the LPN, and did not immediately report the incident. The LPN continued to work his scheduled shift after the incident, as the facility administration did not immediately identify the event as abuse or take appropriate corrective action to protect residents. The LPN was only suspended after administration was made aware of the incident later in the day. Despite the seriousness of the event, the LPN was allowed to return to work after a brief suspension and was not monitored or supervised while administering medications to other vulnerable residents, including those with dementia, who could be at risk of similar abuse. Interviews with staff familiar with the resident confirmed that the LPN's actions were physically, emotionally, and psychologically abusive, and could have resulted in aspiration. The responsible party for the resident stated that having a hand placed over the resident's mouth would have caused significant fear. The facility's failure to recognize, report, and respond appropriately to the abuse, as well as the lack of monitoring of the LPN after the incident, resulted in a finding of immediate jeopardy due to the likelihood of serious injury, harm, impairment, or death to residents.