Failure to Immediately Separate Resident from Alleged Abusive Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to immediately separate a vulnerable resident from a staff member following an alleged abuse incident. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. On the evening of 12/22/25, Staff C was pushing Resident #1 in a wheelchair past the nurses’ station while the resident was yelling out, which staff described as normal for him. Staff A, an LPN, was at the nurses’ station charting when she heard Staff D, a CNA, tell the resident to “shut the fuck up.” Staff A looked up, verbally responded “really” to Staff D, and observed Staff D’s hand moving away from the resident’s face, but did not witness any physical contact. Staff A did not intervene to separate the resident from Staff D and did not assist with putting the resident to bed. Later that evening, after the shift ended, Staff B, a CNA, sent a message to Staff A reporting that she had seen Staff D walk out from behind the nurses’ station, pinch the resident’s lips closed with her thumb and index finger for approximately five seconds, and again tell him to “shut the fuck up” while Staff C continued to assist the resident to bed. Staff B stated that the resident’s yelling out was normal for him and that Staff A was present at the nurses’ station when this occurred. The facility’s Dependent Adult Abuse policy, dated November 2019, required that upon receiving a report of an allegation of resident abuse, the facility immediately implement measures to prevent further potential abuse, including separating the accused employee from all residents by suspension or reassignment. Despite this policy, the alleged abusive staff member continued to work the remainder of the shift on 12/22/25 and returned for the next shift before any separation occurred, and the Administrator later acknowledged the facility should have separated the staff member from others at the time of the incident.
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