F0600

D

Failure to Protect Resident From Physical Abuse and Delay in Reporting Incident

Bristol, Connecticut Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves a resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder who was moderately cognitively impaired, used a wheelchair, and required limited assistance with mobility and personal care. The resident’s care plan identified a risk for refusing care and not waiting for assistance with transfers, with interventions including use of two staff for care and transfers, calm and gentle approach, and clear explanations. During an evening episode of incontinent care, three NAs entered the resident’s room when the resident did not want to be changed and became combative, swinging arms and feet. Two NAs held the resident’s arms while a third NA provided care. During this care, one NA slapped the resident hard on the arm and used an expletive, according to two staff witness statements, while the resident continued to resist by kicking and slapping.

The deficiency also includes the failure of two staff members to immediately report the witnessed physical abuse. Both NAs who observed the slapping did not report the incident at the time it occurred, despite one believing the other would report it, and there was no discussion between them about reporting. As a result, the alleged abuser and the two witnesses continued to work in the facility for two additional days before the allegation was reported to the Nursing Supervisor near the end of a later shift. The facility’s policy required protections for residents through written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and called for an immediate investigation when suspicion or reports of abuse occur, but the delay in reporting and the occurrence of the slapping incident demonstrate a failure to ensure the resident was free from mistreatment.