Failure to Protect Resident from Staff Abuse and Delay in Reporting
Penalty
Summary
Facility staff failed to protect a resident from staff-to-resident verbal and physical abuse. An LPN was observed by a CNA aggressively pushing a resident in a wheelchair out of his room, swearing at him, and continuing to push him toward the nurses' station while the resident attempted to resist by reaching out his arms, placing his feet on the ground, and yelling 'no.' The LPN hit the resident's arm, pulled on the back of his shirt, and then forcefully pushed the resident in his wheelchair into a recliner, causing the resident to fly forward, hit the recliner, and land on the floor. While the resident was on the floor, the LPN attempted to pick him up by the back of his pants, and later kicked the back of the resident's right leg while sitting in the resident's wheelchair next to him. The CNA who witnessed the incident did not intervene to protect the resident or call for additional help. The LPN continued to work on the Memory Care Unit after the incident until the CNA reported the abuse to the RN Supervisor. During this time, the resident was agitated and upset, attempting to get away from the LPN. The resident sustained three skin tears to the bilateral upper extremities. The failure to immediately remove the LPN from the unit placed all residents on the Memory Care Unit at risk for abuse. The resident involved had a history of Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder, with severe cognitive impairment and frequent incontinence. The care plan indicated the resident could be non-compliant and resistive to care, and required substantial assistance with activities of daily living. The incident was substantiated by video surveillance, staff statements, and medical record review, confirming the occurrence of both verbal and physical abuse by the LPN and the lack of timely intervention by other staff.
Removal Plan
- CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700.
- Off duty RN Supervisor #772 called to report the allegation of abuse to the police department.
- RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor.
- Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse.
- ADON #549 notified the DON of the allegation of abuse.
- RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse.
- RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit.
- RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed.
- Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400.
- The DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately.
- LPN #602 was also informed to report to the Police Department for questioning and interviewing.
- RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment.
- RN #740 emailed a request for psychiatric services to evaluate Resident #241.
- ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit.
- LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before.
- RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift nursing staff.
- ADON #549 notified Resident #241's guardian of the allegation of abuse.
- ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241.
- The Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457.
- Psychiatric services responded to an email indicating they would evaluate Resident #241; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention.
- ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education.
- LPN #602 reported to the police department and was interviewed by Lieutenant #457.
- The Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse.
- Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241.
- Resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks.
- Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit.
- Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required.
- Resident Safety Monitoring was completed for five residents.
- Education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed.
- The QAPI Committee met via TEAMS to discuss this allegation of abuse and the mitigation items put into place.
- Psychiatric services evaluated Resident #241 with no new recommendations.
- The Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy.
- Interviews with 15 staff verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge.