Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of neurocognitive disorder with Lewy bodies was not protected from physical abuse by staff. The resident, who exhibited agitation, restlessness, and exit-seeking behaviors, was involved in an incident where staff attempted to prevent him from leaving the facility. During the event, the resident attempted to bite an LPN, and multiple staff, including security personnel, intervened to redirect and restrain him. Eyewitness statements and surveillance footage revealed that the LPN approached the resident from behind, forcibly removed his hand from a door handle, and struck him in the face with an open hand while holding his arm. Security staff assisted in restraining the resident and returning him to his wheelchair. The video evidence confirmed the physical contact, which was corroborated by staff interviews and witness statements, some of which described the action as a hit to the resident's face. The facility's abuse prevention policy requires all possible efforts to reduce the risk of harm or mistreatment and to prevent incidents of abuse. Despite this, the actions taken by the LPN in response to the resident's behavior resulted in physical abuse, as defined by the facility's policy and federal regulations. The incident was not initially substantiated by the facility's internal investigation, but direct observations and video evidence indicated that the resident was not protected from physical abuse during the intervention.