Failure to Protect Resident from Physical Abuse and Ensure Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, schizophrenia, anxiety, and depression was involved in a physical altercation with a staff member. The resident, who had a history of verbal and physical behavioral symptoms, was reported to have been forcefully removed from a couch by a housekeeper. The resident did not recall the event and showed no physical injuries upon assessment, but later stated that the housekeeper hit them in the face near the left eye. Another resident, who had no cognitive impairment, witnessed the incident and reported seeing the housekeeper and the resident pushing each other, with the housekeeper hitting the resident in the eye. This witness was initially unsure about reporting the incident but eventually informed the receptionist. Additional staff interviews revealed that some staff heard or observed parts of the altercation but did not immediately report the incident, believing it had been resolved or that others would report it. The facility's abuse and neglect policy required immediate reporting and investigation of any suspected abuse. However, multiple staff members failed to report the incident promptly, and the housekeeper involved was later terminated for failing to report the altercation. The deficiency was identified through observation, interviews, and record review, confirming that the facility did not ensure the resident was free from physical abuse by a staff member.