Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, resulting in a physical altercation between a resident with a history of Schizophrenia, Bipolar Disorder, and Depression, and a Certified Nurse's Assistant (CNA). The resident's care plan identified her as being at risk for abuse or neglect due to self-isolation, use of psychotropic medications, hallucinations, delusions, compulsive behavior, and a history of aggression. The care plan specifically instructed staff to ensure the resident's safety, walk away if she became difficult during care, and allow her time to calm down before reapproaching. Despite these instructions, a conflict arose over a chair, during which the resident threw water at the CNA, and the CNA allegedly struck the resident in the eye, resulting in visible injuries including swelling, scratches, abrasions, and discoloration around the left eye. Multiple staff interviews and progress notes confirmed that the resident reported being hit by the CNA, and that her account of the incident remained consistent. Staff observed the resident on the floor with injuries that did not appear consistent with a simple fall, and another CNA reported hearing sounds of a fight and the resident screaming. The CNA involved denied hitting the resident, stating that the resident fell while she was removing the chair from the room, possibly slipping on water. However, the resident maintained that she was punched in the eye, and staff noted that her injuries were more severe than what would be expected from a fall alone. The facility's abuse policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent abuse, neglect, and mistreatment. Despite this policy, the incident demonstrates a failure to follow the resident's care plan and to protect her from harm. The CNA's actions, including entering the resident's room against her wishes and engaging in a physical struggle over the chair, directly contributed to the resident's injury and emotional distress. The event was reported to the police, and the CNA was suspended pending investigation.