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F0600
G

Failure to Prevent Physical Abuse and Forced Medication Administration

State College, Pennsylvania Survey Completed on 10-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of refusing care and medications, as well as exhibiting physical and verbal aggression toward staff, was found to have multiple bruises on her left upper arm. The bruises were discovered after the resident's son reported them to an LPN, who observed three oddly shaped bruises but was unable to measure them due to the resident's refusal. The incident that led to the bruises occurred when staff attempted to administer Ativan to the resident, who resisted and knocked the medication out of the nurse's hand. Multiple staff members were involved in restraining the resident, with one nurse aide placing the pills in the resident's mouth and holding her mouth closed until the medication dissolved, while others held her limbs during the process. Interviews with staff revealed that the nurse aide used excessive physical force, including grabbing the resident's arms and holding her mouth shut, which resulted in the bruising. Staff accounts also indicated that the resident was physically aggressive during the incident, striking and scratching staff members, but the response from staff involved actions outside their scope of practice and the use of physical restraint to administer medication against the resident's will. The nurse aide involved was later heard stating that she made the resident take the pills because she had been scratched. The facility's investigation found that the care plan for the resident did not include specific behavioral interventions suggested by the resident's son, despite her known history of non-compliance and aggressive behaviors. The incident was not reported to the Director of Nursing or other appropriate authorities in a timely manner, as the DON only became aware of the situation two days after it occurred, following the discovery of the bruises. The failure to implement appropriate care plan interventions, prevent physical abuse, and ensure timely reporting contributed to the deficiency.

See complete original report
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