Failure to Protect a Resident From Physical Abuse During Wound Care
Penalty
Summary
The facility failed to protect a resident from physical abuse when the Director of Nursing Services (Staff B) slapped the bare buttock of a resident following a dressing change. The facility’s abuse prohibition policy, dated 10/24/2022, defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that physical abuse included hitting and slapping. The policy also stated that the Administrator was responsible for operationalizing abuse-prevention policies, that any employee alleged to have committed abuse would be immediately removed from duty pending investigation, and that anyone witnessing suspected abuse must report it to outside agencies such as the state survey agency and local law enforcement. Resident 1 had multiple diagnoses including stroke with hemiparesis, dementia, bipolar disorder, and anxiety disorder, and required extensive assistance with bed mobility and toilet hygiene. The resident had an indwelling urinary catheter, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. On or before 12/23/2025, during a dressing change after the resident had a bowel movement that soiled the wound dressing, Staff B completed the dressing change and then slapped the resident on the bare buttock. Three NAs (Staff D, E, and F) were present; two reported witnessing the slap, and one reported that the resident questioned the action and Staff B replied it was “just to let you know I was done.” Staff B later told the RN Resource Clinician (Staff C) they had “tapped” the resident on the buttock and that staff in the room reacted. Staff C spoke with the resident hours later, did not interview the staff witnesses, and did not report the incident further at that time, despite later acknowledging it should have been reported sooner.
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