Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with vascular dementia, psychosis, and major depressive disorder, who had significant cognitive impairment and required moderate assistance with transfers and ambulation, was involved in an incident in the dining room. The resident, who had been confused and argumentative, was observed sitting at a table before standing up with a fork in hand. A staff member, an LPN, approached the resident despite the resident's agitated state. The LPN and the resident exchanged words, and the LPN continued to walk towards the resident. Video surveillance and witness interviews indicated that the LPN made physical contact by pushing the resident, causing the resident to fall to the floor. As a result of the fall, the resident sustained fractures to the right distal radius and ulna, requiring medical intervention and hospitalization. Facility documentation and interviews confirmed that the LPN should not have engaged with the resident while agitated and should have avoided physical contact. The facility's abuse and neglect policy states that residents have the right to be free from abuse, including physical abuse by staff. The incident demonstrated a failure to protect the resident from physical abuse, as the staff member's actions directly resulted in harm to the resident.