Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia, diabetes mellitus, and major depressive disorder, was subjected to physical abuse by a staff member. The incident took place in the dining room during lunch, when the resident took another resident's cake, leading to an argument with an LPN. During the altercation, the resident spat at the LPN, who then responded by slapping the resident on the right cheek. This act was witnessed by two certified nurse aides, and the resident was observed to have redness and swelling on the right cheek and was crying immediately after the incident. The resident's care plan indicated a need for ongoing redirection, monitoring, and structured activities due to behavioral symptoms and a risk of victimization related to dementia. Despite these documented needs, the staff member engaged in a physical confrontation rather than employing de-escalation or redirection techniques. The incident resulted in observable physical harm and psychosocial distress to the resident, as evidenced by immediate crying and the need for consolation by staff. Interviews with staff confirmed that attempts were made to intervene and de-escalate the situation, but the argument continued, culminating in the physical abuse. The LPN involved acknowledged the incident and expressed regret, while other staff members promptly reported the event to facility leadership. The deficiency centers on the failure to protect the resident from abuse by a staff member, contrary to facility policy and regulatory requirements.