Failure to Protect Resident From Physical Abuse and to Report and Investigate Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired male resident from physical abuse and to ensure staff were trained and knowledgeable in responding appropriately to resident behaviors. The resident, with metabolic encephalopathy, bipolar disorder with psychotic features, lack of coordination, muscle weakness, muscle wasting and atrophy, a lumbar vertebral compression fracture, a history of falls, and a BIMS score of 6 indicating moderate cognitive impairment, required supervision or assistance with personal hygiene, transfers, bed mobility, toileting, dressing, and bathing. Nursing documentation shows that on one morning the resident was yelling loudly and continuously in the hallway, and when a CNA entered his room, he was irritated and agitated, struck the CNA four times, and attempted to strike her in the face. The CNA reported grabbing the resident’s arm to prevent being struck, after which the resident pulled his arm away, resulting in a skin tear. Later that day, nursing documentation identified a 5 cm x 2.5 cm skin tear on the resident’s left forearm, which was treated, and the NP and Administrator were notified. The resident’s family member reported being notified that a CNA had grabbed the resident’s arm and caused a laceration during ADL care in his room and stated that video she viewed showed the CNA grabbing the resident’s arm while assisting him back to bed, although she did not provide the videos. CNA A stated that the resident had severe behavioral issues, including screaming, yelling, throwing objects, hitting staff, and attempting to break things, and that he often required one-on-one attention. She described an incident in which the resident struck her multiple times in the chest during ADL care, and she reacted by grabbing his hand and blocking him from hitting her again, which caused a small skin tear on his arm. She indicated she was unsure if an investigation had been done and that she had not been suspended after the incident. The Administrator stated she was on vacation when notified that CNA A had grabbed the resident’s arm, causing a skin tear, and that the DON was the assigned abuse coordinator and should have reported the incident to the state. She acknowledged she did not personally report the incident, investigate the allegation, or suspend the alleged perpetrator, and said she assumed the DON had reported it. She also stated that a state surveyor later told her she did not need to report it. LVN A reported that the resident had moderate dementia with behavioral disturbances that escalated with family involvement and camera installation, and confirmed witnessing the resident attempt to hit CNA A, who then grabbed his hand, causing a skin tear, and that she reported the incident to the DON and Administrator. Both CNA A and LVN A stated they had not received behavioral training at the facility, despite the facility’s Abuse Investigation and Reporting policy requiring all alleged violations involving abuse, neglect, or injuries of unknown source to be reported immediately, but no later than two hours if abuse or serious injury is suspected, to the administrator and appropriate agencies, and requiring a thorough internal investigation and timely notification of outcomes.
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