Failure to Protect Resident from Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in actual harm. A resident with diagnoses including tremors, insomnia, disorientation, Parkinsonism, and dementia was found with multiple bruises and swelling on the right side of the face, both legs, and both hands. The injuries were discovered in the morning and were not present the previous evening, as confirmed by staff. The resident, who primarily speaks Vietnamese and has impaired cognitive function, was unable to fully communicate the incident to staff without assistance from a multi-lingual visitor and later a translation service. Through translation, the resident reported that a large female staff member entered his room at night, instructed him to straighten his legs, and then struck him multiple times with a shoehorn on his legs, face, hands, and thigh. The resident did not call out or attempt to report the incident at the time. Staff interviews and clinical record reviews confirmed that the injuries were consistent with the resident's account and were not observed prior to the alleged incident. The resident later identified the staff member involved from photographs, and the facility's investigation substantiated the abuse. Witness statements from multiple staff members, including LPNs and NAs, indicated that no injuries were observed on the resident during their shifts prior to the morning the injuries were discovered. The shoehorn used in the incident belonged to the resident and was found in his room. No other residents reported abuse by the implicated staff member. The incident resulted in mental anguish and physical harm to the resident, as evidenced by the documented injuries and the resident's emotional response during subsequent interviews.