Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hypertension and anxiety disorder reported being struck on the upper lip with a bottle by a certified nursing assistant. The incident was initially reported to an LPN, who observed slight swelling to the resident's upper lip. The DON assessed the resident and confirmed the swelling, but no bruising or bleeding was noted at that time. The resident consistently identified the same staff member as the alleged perpetrator, and multiple staff interviews confirmed the resident's report of being hit with a bottle, although the specific bottle was not located in the room. The facility's investigation included interviews with the alleged staff member, who denied the incident, and other staff who responded to the resident's call bell. One CNA reported that the accused CNA admitted to throwing a bottle at the resident after being hit, but this was not corroborated by physical evidence. The resident was placed on frequent monitoring and referred for psychiatric and psychological evaluation. Subsequent medical assessment documented increased swelling and bruising to the resident's lips, including new areas of discoloration inside the mouth. Despite the resident's consistent statements and physical findings, the facility concluded there was no evidence of abuse, neglect, or mistreatment, citing the absence of the bottle and conflicting staff accounts. The investigation did not substantiate the resident's allegation, and the accused staff member was removed from the schedule but did not return to the facility. The deficiency centers on the facility's failure to ensure the resident was free from abuse, as required by policy and regulation.