Failure to Protect Resident from Abuse and Neglect During Medication Request
Penalty
Summary
On the evening of 08/19/2025, a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision was involved in an incident with an LPN. The resident, who had moderately impaired cognition but was independent with eating, bed mobility, and wheelchair use, was observed on video surveillance seated in their wheelchair in the doorway of their room. The LPN, while at the medication cart, engaged in a verbal exchange with the resident, who was requesting pain medication. The LPN turned around, moved behind the resident's wheelchair, and attempted to hold the resident's hand down and force them back into their room, despite the resident resisting and holding onto the doorway frame. The LPN continued to attempt to pull the resident into the room by holding onto their hands and shoulders, even as the resident resisted these actions. Multiple interviews corroborated the events seen on video. The resident reported that the LPN appeared upset, refused to provide pain medication, and physically pulled their wheelchair backward while holding their arms. A family member stated the resident informed them that the LPN refused to provide pain medication and put hands on the resident without permission. Certified Nurse Aide #1 heard yelling and observed the LPN wheeling the resident backward into their room, reporting the incident to the night nurse. The LPN involved stated they were running late with medication pass and were unable to provide the pain medication, and that they became scared when the resident began yelling, leading them to attempt to bring the resident back into their room. Further, another LPN and the Director of Nursing confirmed that the LPN was still passing medications late into the shift and that the resident was upset about not receiving pain medication. The second LPN observed the first LPN attempting to push the resident back into their room while yelling and intervened to stop the situation. The Director of Nursing acknowledged that the incident could have been prevented and that staff should not place their hands on a resident to force compliance, especially when the resident is upset. The facility failed to ensure the resident was free from abuse, neglect, and mistreatment during this incident.