Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A severely cognitively impaired resident with Alzheimer's disease, dementia, and behavioral disturbances was involved in an incident where a nurse aide struck her on the left side of her face during care. The resident was known to be agitated and combative during incontinence care, often requiring two staff members and specific interventions such as re-approaching or using diversions to manage her behaviors. On the night of the incident, two nurse aides were providing care when the resident became combative, and after the resident struck one of the aides, that aide responded by slapping the resident with an open hand. The incident was witnessed by the other nurse aide, who reported hearing the accused aide threaten to hit the resident back if struck. The witness observed the slap and described it as a loud clap. The witness was initially afraid to report the abuse in the presence of the accused aide but promptly notified a nurse via text, who then escalated the report to the facility administrator. The resident was assessed following the incident, and small petechiae were noted on her left cheek, but no significant injury or distress was documented. The resident's Power of Attorney also observed marks on the resident's face the following morning and reported the incident to Adult Protective Services. Interviews with staff and the resident's Power of Attorney confirmed the sequence of events, with the accused aide denying the slap and the threat. The resident was unable to provide a coherent account due to her cognitive impairment. The facility's investigation did not substantiate the abuse allegation, citing lack of injury or mental anguish, but the aide involved was terminated. The deficiency centers on the failure to protect the resident from physical abuse by staff during care, despite the resident's known behavioral challenges and the facility's established interventions for managing such behaviors.