Failure to Protect a Resident From Physical Abuse and to Implement Abuse Protocols
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to follow its Abuse Prevention Program and abuse/neglect protocols. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and was documented as having capacity to understand and make decisions, reported that during a therapy session he touched the back of a physical therapist’s head to get his attention. In response, the therapist turned toward him and slapped him on the right thigh with an open hand. The resident stated the slap stung his leg, that the therapist appeared very angry and mean, and that he felt angry, shocked, upset, and assaulted. The resident reported that he had previously considered the therapist a friend and did not initially want to complain because he did not want to get anyone in trouble and considered himself a strong person. Another physical therapist in the room (PT 2) witnessed the incident and stated that the resident flicked the back of PT 1’s head, after which PT 1 rotated his chair and struck the resident once on the right thigh with an open hand. PT 2 described the slap as very loud, like someone slamming their hands on a desk, and reported that the resident yelled, “no, you can’t do that,” and “you beat me,” and appeared shocked and upset. PT 2 also reported that PT 1 often seemed annoyed with the resident and had, on multiple occasions, spoken loudly to him, telling him he talked too much and needed to be quiet. PT 1 acknowledged that the resident had touched or slapped the back of his head, that he was startled, and that he immediately turned and slapped the resident, though he claimed he slapped the resident’s hand and spoke in a low voice telling him to stop. The facility failed to identify and respond to this incident as abuse at the time it occurred. The incident was not immediately reported to the Administrator or nursing staff on the day it happened, and the resident was not immediately monitored after the slap. PT 2 allowed therapy to continue with both therapists remaining in the room and did not remove PT 1 from the resident’s presence, despite witnessing the slap and the resident’s reaction. PT 2 stated she did not report the incident immediately because she believed there was a 24‑hour reporting window, wanted to give PT 1 an opportunity to report it himself, and the resident had asked her not to report it. The incident was reported the following day after it was learned that PT 1 had not reported it. The facility’s Abuse Prevention Program stated that residents have the right to be free from abuse, including physical abuse and corporal punishment, and that administration would protect residents from abuse by anyone, but these protections were not implemented at the time of the event.
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