Failure to Protect Resident from Physical and Verbal Abuse Due to Lack of Behavior Care Planning
Penalty
Summary
A resident with dementia, major depressive disorder, and osteoarthritis was admitted to the facility and began exhibiting aggressive and resistive behaviors within the first two weeks. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with individualized interventions to guide staff in managing these behaviors. The resident's medical provider was not consistently notified of the increased behaviors, and there was no documentation of timely follow-up when the provider did not respond to staff communications regarding the resident's condition. On one occasion, the resident became agitated and resistive during care. A CNA attempted to calm the resident, but a registered nurse entered the room, yelled at the resident, and physically handled the resident by grabbing and throwing the resident's legs into bed, restraining the resident with a blanket, and shaking the resident's shoulders while yelling in the resident's face. The resident reported feeling afraid during this interaction. Staff interviews revealed that the nurse involved had a known history of stress-related outbursts, though not previously directed at residents. The incident was witnessed by another staff member, who intervened and reported the abuse immediately. The facility's policy required monitoring for staff burnout and the development of care plans for residents with challenging behaviors, especially those with cognitive deficits. However, the facility did not initiate a behavior care plan for the resident despite repeated aggressive incidents, nor did it ensure timely communication with the resident's provider. This lack of appropriate planning and intervention contributed to an environment where a staff member engaged in physical and verbal abuse of a vulnerable resident, resulting in a finding of immediate jeopardy.
Removal Plan
- All staff education on verbal and physical abuse.
- All staff education on resident's rights including: Freedom from mistreatment, Freedom from physical restraints, Treatment options (including the right of the resident to refuse care or treatment), Self-determinations (including the right of the resident to make decisions relating to care), and the Right of the Resident to be treated with courtesy and respect.
- All staff meeting which included additional abuse training, as well as burnout and stress management of staff. Staff not in attendance had the training available online to view.
- Audit included check-ins with residents to cover any resident concerns. Audits will continue.
- Audit included check-ins with staff to cover abuse, and staff stressors. Audits will continue.
- Grievance audit included facility staff reviewing resident grievances each weekday. Staff to audit for any area of concern related to abuse or misconduct.
- Staff interviewed other residents in the facility.
- Police were notified.