F0600

D

Failure to Prevent Physical Abuse During Wound Care

San Jose, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse during wound care. The resident had osteomyelitis of the vertebra and physician’s orders for treatment of a coccyx pressure injury and a left buttocks open wound, including cleansing with normal saline or Dakin’s solution, application of Santyl ointment, collagen, calcium alginate, and foam dressings twice daily or as needed. During wound treatment, a licensed vocational nurse (LVN A) was observed on a video recording provided by the resident standing on the left side of the bed while the resident lay face down. After pressing down the tape around the wound dressing with his gloved fingers, LVN A made a fist with his right hand and punched the resident’s wound on top of the dressing, causing the resident to scream in pain and shout obscenities.

In interviews, the resident reported that prior to setting up the video recording, LVN A had punched his wound three or four times and, on other occasions, slapped the wound. The resident stated he was afraid to report LVN A and described that sometimes LVN A would perform the wound treatment, then leave the room with the resident’s pants down, the curtain open, and the door open, which the resident found humiliating. Another resident corroborated the abuse, stating he witnessed LVN A hitting, squeezing, or slapping the resident’s wound multiple times and also hitting him across the backside. The facility’s abuse prevention policy states that residents have the right to be free from abuse and that administration will protect residents from abuse by anyone, but the described actions of LVN A toward the resident’s wound and exposure during care constituted abuse that was not prevented.