Failure to Protect Dependent Resident From Possible Physical Abuse and Unexplained Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent resident from physical abuse and to ensure the resident remained free from injuries of unknown origin. The resident had hemiplegia and hemiparesis affecting the left side, aphasia, depression, and anxiety, with a BIMS score of 3 indicating severely impaired cognition. The care plan documented that the resident was dependent on staff for bed mobility and transfers and required assistance of one staff member for activities of daily living and transfers in and out of bed and chair. The resident was also identified as at risk for falls due to decreased functional mobility and hemiplegia/hemiparesis. On the evening in question, an LPN reported that the NA assigned to the resident approached him in an upset and erratic manner, stating she should not be working because it was her mother’s birthday, and then left the shift early. When the LPN entered the resident’s room to administer medications, he discovered the resident with multiple injuries, including a swollen right lip with a laceration, an abrasion and quarter-sized bump on the forehead, and bruises on the back of the right wrist and thumb area. The resident, who communicated primarily through yes/no responses due to aphasia, initially nodded no when asked if he had fallen or bumped his head and was unable to explain how the injuries occurred. The facility documented this as an injury of unknown origin. Subsequent interviews and observations further highlighted the unexplained nature of the injuries and the possibility of abuse. Another NA who came on after the first NA left reported that the resident was incontinent of stool, required assistance of two staff for personal care, and that stool was found on the floor near the bed when she later provided care and observed the injuries. The DON stated the resident would not have had the ability to get up independently and would likely require two staff to assist if a fall had occurred, and there were no residents on the unit who wandered or had a history of aggression. In a later interview, the resident, with a family member present, verbally identified that the NA who had left the shift early had struck him, and demonstrated this by forming a fist and touching his forehead, while also acknowledging a fall but without being able to provide details. The facility’s own abuse policy required that injuries of unknown origin be investigated as potential abuse when the source is not observed or cannot be explained, or when the injury is suspicious due to its extent, location, or number, conditions that were present in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.