Failure to Protect Resident From Emotional Abuse and to Immediately Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from emotional/mental abuse and to immediately remove the alleged staff perpetrator from resident contact after an abuse allegation. A cognitively intact resident with multiple chronic medical conditions, including coronary artery disease, CHF, COPD, CKD, schizoaffective disorder (bipolar type), major depressive disorder, and nicotine dependence, used a wheelchair for mobility and depended on staff for transfers. The resident had a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation that the resident would be treated with respect and dignity and live free from mistreatment. On the evening in question, the resident was propelling himself in his wheelchair toward the designated smoking area with an unlit cigarette in his mouth so that both hands were free to move the wheelchair. Two CNAs reported that the LPN at the nurses’ station got up, approached the resident, and snatched the unlit cigarette out of the resident’s mouth, broke it in half, and, per the resident and the Administrator, threw it at the resident. The CNAs stated the LPN did this without first speaking to the resident and described the LPN as rude. The resident and both CNAs reported that the LPN told the resident he was not supposed to have the cigarette in his mouth, and the CNAs further reported that the LPN yelled at the resident and threatened to call the police on him as a way to scare or intimidate him. The resident stated he was not trying to smoke in the building and that he was not scared by the threat, but he was upset and intended to report the LPN. One CNA stated she immediately texted the DON to report what she believed was emotional/mental abuse based on her training, and the other CNA stated she knew this report was made that night. Both CNAs later wrote statements dated two days after the incident. The DON stated that staff are expected to report abuse immediately, that staff-to-resident abuse requires immediate separation of the staff from the resident and removal of the staff from the building, and that this is necessary to ensure resident safety and prevent continuation of abuse. The Administrator, who is the abuse coordinator, similarly stated that staff must report suspected abuse immediately, that it is not their role to determine whether abuse occurred, and that any staff member involved in alleged abuse must be removed from the building and placed on administrative leave pending investigation. The Administrator stated that the first time he became aware of the incident was when the resident reported it to him two days later, at which time he learned that the LPN had snatched the cigarette from the resident’s mouth and threatened to call the police, actions he acknowledged could be intimidating, humiliating, and a form of abuse. Facility records showed the LPN continued to work after the incident and was not removed from the building the night of the alleged abuse, contrary to the facility’s abuse prevention policy, which requires immediate separation of the alleged perpetrator and notification of the Administrator and DON when abuse is suspected.
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