Staff-to-Resident Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a staff member struck the resident in the face during an altercation. Facility policy titled “Freedom from Abuse Neglect and Exploitation,” revised in September 2025, required the facility to provide a safe environment and protect residents from verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Despite this policy, a dietary supervisor engaged in a physical confrontation with a resident and admitted to hitting the resident after the resident attempted to swing at him. The resident involved, identified as having diagnoses including epilepsy, hypertension, COPD, dementia, and unspecified psychosis, had a comprehensive MDS dated November 19, 2025, indicating moderate cognitive impairment. On the date of the incident, information submitted by the facility stated that the resident was physically aggressive toward staff, attacked and hit a dietary employee in an elevator, and later attacked another employee who then “took a swing” at the resident. The facility’s investigation documented that the dietary aide reported being approached and punched in the face by the resident while in the elevator, and that he informed the dietary supervisor of this event. According to the dietary supervisor’s written and verbal statements, after being notified that the resident had hit the dietary aide, he went to locate the resident and attempted to calm the situation. He reported that the resident became aggressive, that he asked the resident to stop multiple times, and that when he tried to exit the situation the resident took a swing at him. The dietary supervisor stated that he then swung back and hit the resident. A resident witness reported seeing the resident put hands up to fight and observed the dietary supervisor hit the resident back after being struck. An activity aide reported seeing the resident with fists balled up and observed the dietary supervisor hit the resident on the side of the face, though she did not see the resident hit the supervisor. The nursing supervisor’s statement indicated she saw the resident punch the dietary supervisor, after which the dietary supervisor began hitting the resident and said, “you messing with the wrong one,” while punching the resident in the face. Based on these documents and interviews, surveyors determined that a staff member striking a resident with moderate cognitive impairment constituted abuse and caused actual harm, compromising the resident’s right to be free from abuse.
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