Failure to Protect Cognitively Impaired Resident From Verbal and Physical Abuse by Podiatrist
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from verbal and physical abuse by an ancillary service provider, specifically the podiatrist. The resident had Alzheimer’s disease, dementia, anxiety disorder, osteoarthritis, muscle weakness, unsteadiness on feet, and auditory and visual hallucinations, and was documented as severely cognitively impaired with a BIMS score of 01. She required one-person assistance with ADLs, ambulated with a 4‑wheeled walker, and her daughter was the DPOA and decision maker. On observation the day after the incident, the resident was fully dressed, sitting on the side of the bed with her walker in front of her, talking to herself, not engaging with the surveyor, and appeared calm and free from visible bruises. According to staff interviews, CNA A, the DOR, and PTA D were in a nearby room when they heard thumping, scuffling, loud noises, and a male voice yelling and swearing coming from the resident’s room. CNA A reported hearing the podiatrist say, “Don’t f*ck*ng hit me,” and then, upon entering the hallway, observed the resident about three feet from her bed moving toward the podiatrist. CNA A stated he saw the podiatrist push the resident, causing her to fall back onto her bed, and heard the resident yelling at him to get out. CNA A described the podiatrist attempting to leave the area and trying to get past him, while CNA A blocked his path and instructed him not to go by other residents. PTA D corroborated hearing aggression in the male voice, yelling, swearing, and the resident being upset. The DOR reported hearing a man swearing and clearly saying, “Do not F*ck*ng lay hands on me again,” followed by CNA A stating that the resident needed help and that he had witnessed abuse. When the DOR entered the resident’s room, she found the resident on her bed with glasses askew, arms flailing, yelling, crying, and physically upset. The DON’s documentation and interview indicated that staff had reported raised voices and that the podiatrist was observed yelling at the resident, with staff reporting that the resident was attempting to ambulate past him when he pushed her back onto the bed. A post‑incident assessment noted redness on the resident’s left forearm in a broad irregular shape and a complaint of right wrist pain, though she was able to move the wrist without observable signs of pain. During assessment, the resident was tearful, resistant to touch, and repeatedly hugged a stuffed dog, and she stated that people had been “beating [her] with hammers.” The DON also reported that the podiatrist stated the resident had assaulted him and that he had previously entered resident rooms alone to provide services. These events demonstrate that the resident was subjected to verbal and physical abuse by the podiatrist, contrary to the facility’s abuse policy defining abuse as willful infliction of injury, intimidation, or conduct causing or potentially causing humiliation, fear, or mental anguish.
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