Failure to Prevent Verbal and Physical Abuse During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes, and hyperlipidemia was subjected to verbal and possible physical abuse by an LPN during a transfer using a sit-to-stand lift. The resident's care plan specified that, in the event of conflict, she should be placed in a calm and safe environment and allowed to vent. However, during the transfer, the LPN was observed by the Assistant Director of Nursing (ADON) and a CNA to be yelling at the resident, telling her to stop acting like a child, and appeared to push the resident into a chair while the sling was still around her waist. The incident was documented in the nurse's note and corroborated by witness statements. The LPN involved had received annual re-education on psychosocial needs and abuse prevention, as indicated in her personnel record. Despite this training, the LPN's actions did not align with facility policy, which states that residents have the right to be free from abuse, neglect, and exploitation. The incident was reported to facility leadership, and it was determined that the facility failed to maintain an environment free of abuse for the resident, as required by state regulations.