Failure to Protect Resident From Physical and Verbal Abuse and to Immediately Remove Abusive LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a staff member and to immediately remove the alleged perpetrator from resident contact after the abuse was witnessed. On the date of the incident at approximately 4:00 PM, an LPN physically and verbally abused a resident identified as moderately cognitively intact, with a BIMS score of 12 on a recent MDS. The LPN hit the resident repeatedly on the face, head, shoulders, arms, and chin area with a closed fist, placed her knee on the resident’s neck to pin him down, grasped his shirt and attempted to drag him across the floor, and yelled profanities at him, including “b***h, don’t hit me,” “b***h, don’t touch me,” “b***h I’m tired of you,” and “b***h get off of me.” This conduct was directly witnessed by two CNAs and another resident, who was cognitively intact with a BIMS score of 15. During the incident, one CNA intervened by getting the resident to release the LPN and give her his hands, after which the LPN initially got up as if to walk away, then turned back, put her knee on the resident’s neck, and continued to strike him. The CNAs reported that it appeared the resident could not breathe with the LPN kneeling on his neck, prompting them to pull the LPN off the resident. The LPN then walked away, returned, and again attempted to drag the resident by his shirt on the floor. Throughout this time, the LPN continued to verbally abuse the resident and instructed the CNAs, in the resident’s presence, to “leave that b***h on the floor, don’t help him up.” Later, around 5:00 PM, when one CNA was preparing to make rounds, the LPN again verbally abused the resident by instructing the CNA, in front of the resident, to “leave that b***h in his chair.” The resident later stated in an interview that the LPN had previously hit him. Despite witnessing the physical and verbal abuse, the CNAs did not immediately report the incident to the Administrator or remove the LPN from resident contact. Instead, both CNAs left the floor for approximately eight minutes to find assistance to get the resident off the floor, leaving the LPN alone with the abused resident and approximately 20 other residents on that floor. One CNA stated she was in shock and did not know what to do, and the other CNA indicated that at the time of the incident she did not know who to report abuse to. During the period from approximately 5:00 PM to 6:00 PM, one CNA only periodically visualized the resident and the LPN while completing rounds and did not constantly monitor them, leaving the LPN with ongoing access to the resident and other residents. Facility leadership, including the Administrator and DON, later acknowledged that the LPN should not have been left alone with residents after the abuse occurred and that the physical and verbal abuse should not have happened.
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