Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a housekeeper forcefully and unnecessarily moved a male resident with diagnoses including COPD, dementia, major depressive disorder, and a history of falls. The resident, who is care planned as being at risk for abuse/neglect and ambulates independently by wheelchair, was observed on facility surveillance footage being spun around aggressively by the housekeeper while attempting to resist by placing his feet on the floor. The housekeeper then tilted the wheelchair back and pushed the resident away from the area in an aggressive manner, despite the resident's nonverbal cues indicating he did not want to be moved. There were no other witnesses to the incident, and the event was captured on video during a routine review by corporate staff. The resident later confirmed the incident during an interview, recalling that the housekeeper spun his wheelchair and moved him from the area after he exited the elevator, and that he tried to stop the movement by putting his feet down. The housekeeper had previously attended an inservice on abuse and neglect. The facility's abuse prevention policy states that residents must be free from all forms of abuse, including physical and mental abuse. The incident demonstrated a failure to protect the resident's right to be free from physical abuse.