Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a facility failed to protect a resident from physical abuse by a staff member. The incident involved a male resident with severe intellectual disability, schizoaffective disorder, ADHD, cerebral palsy, and cognitive communication deficits, who had a BIMS score indicating severe cognitive impairment. On the evening in question, the resident became combative with his roommate and staff, requiring intervention from two CNAs and an LVN. During the attempt to assist the resident, the LVN was witnessed by both CNAs to have grabbed the resident by the shirt near his neck and made a choking noise, causing the resident to cry. The LVN's actions were in response to the resident using a racial slur, and both CNAs confirmed the physical contact and the resident's distress during interviews. The resident himself reported being choked and expressed fear of the LVN during an interview. The facility's documentation and staff interviews confirmed that the LVN entered the resident's room after being called for assistance due to the resident's combative behavior. The LVN admitted to having his hand caught in the resident's shirt near the neck but denied intentionally choking the resident. However, both CNAs present in the room described the LVN grabbing the resident by the shirt at the neck and getting into his face after the resident used a racial slur. The CNAs reported that the resident made a choking noise and cried after the LVN released him. The incident was also discussed in a voice recording provided by one of the CNAs, where both CNAs recounted the LVN's actions to him, and the LVN did not deny the events but stated he did not remember. The facility's policies prohibit any form of abuse or neglect, and the administrator stated that staff are expected to act professionally and not choke residents or react to verbal provocations. The LVN involved was terminated following the incident. The resident was assessed and found to have no physical injuries, but the incident was substantiated through multiple staff interviews, resident statements, and documentation. The failure to prevent and immediately address the physical abuse by the LVN constituted a deficiency in protecting residents from abuse.