F0600

J

Failure to Protect Resident from Physical Abuse by Housekeeper

Youngstown, Ohio Survey Completed on 09-24-2025

Penalty

No penalty information released

Summary

A deficiency occurred when a housekeeper physically abused a resident by pushing the resident in his wheelchair, causing him to fall and hit his head on a medication cart. The housekeeper then placed his hands around the resident's neck and punched him with a closed fist. Multiple staff members witnessed the incident, and the resident was subsequently found sitting on the floor, refusing immediate assessment and assistance. The incident was also captured on video, which showed the housekeeper approaching the resident, placing both hands on the resident's neck/shoulder area, and pushing him out of the frame. Staff members responded to the altercation, and the resident was later transferred to the emergency room for evaluation at his brother's request.

The resident involved had a history of multiple medical and psychiatric conditions, including a recent femur fracture, diabetes, repeated falls, substance dependencies, bipolar disorder, depression, insomnia, and anxiety. At the time of the incident, the resident was cognitively intact, required supervision for all activities of daily living, and used a wheelchair for mobility. The care plan identified risks for mood disruptions and falls, with interventions in place for behavioral support and safety education. Despite these interventions, the resident became involved in a verbal altercation with housekeeping staff, which escalated to physical abuse by the housekeeper.

Witness statements from staff, including CNAs and LPNs, corroborated the resident's account of being choked, punched, and pushed, resulting in a fall from the wheelchair. The police were called, and a report was filed. The resident reported pain and had a small abrasion on his lower back but declined immediate pain medication and assessment, preferring to wait for his brother before going to the hospital. The incident was reported to the state agency, and the facility's abuse policy defined the actions as physical abuse. The deficiency was cited as Immediate Jeopardy and Actual Harm due to the failure to protect the resident from abuse.

Removal Plan

• Social Service Designee (SSD) #524 separated Housekeeper #582 and Resident #66 and provided for resident safety.
• Housekeeper #582 was suspended pending investigation by the Administrator.
• The Director of Nursing (DON) notified Medical Director #585 and Resident #66's emergency contact/brother of the incident.
• The Administrator notified the local police department.
• The Administrator collected witness statements from facility staff that observed the incident.
• The Administrator changed all of the door codes in the facility (to prevent unauthorized access to the building).
• The Administrator reviewed the facility abuse policy with no changes to the policy deemed necessary.
• The Administrator initiated training on the facility Abuse Policy, Aggressive and Combative Behavior Management Policy, and Resident Rights with all staff, including initiation of a posttest with a theme of Just Walk Away! The training was completed.
• Resident #66 was transferred to the local ER for evaluation per his brother's request.
• SSD #524 interviewed all interviewable residents in facility related to abuse.
• Registered Nurse (RN) #538 completed skin checks on residents unable to be interviewed related to abuse.
• RDCO #578 completed training on Abuse Policy with all staff via OnShift.
• RDCO #578 completed training on policy on Management of Combative and Aggressive Behavior with all staff via OnShift.
• RDCO #578 completed training related to Identifying, Preventing and Managing Aggressive Behaviors with all staff via OnShift.
• RDCO #578 completed training on resident rights policy with all staff via OnShift.
• SSD #524 assessed Resident #66's psychosocial status at baseline psychosocial status.
• The Administrator in collaboration with Healthcare Services Group terminated Housekeeper #582's employment.
• The Administrator reiterated to Human Resources #587 to continue to ensure newly hired employees were educated on the abuse policy upon hire during orientation.
• The facility implemented a plan for SSD #524 to conduct interviews with five employees weekly related to abuse and five residents weekly related to abuse for four weeks, then monthly for two months. Compliance with the interviews would be overseen by the Administrator. Results of the interviews would be reviewed with the Quality Assurance and Performance improvement (QAPI) committee for additional recommendations as warranted.