Failure to Thoroughly Investigate Allegation of Physical Abuse by Private Duty Assistant
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse. The facility became aware of an allegation on 08/20/25 at 2:30 pm, when a construction company foreman reported that one of the construction staff had witnessed a staff member hitting Resident #1 in the head sometime during the previous week. Resident #1 was admitted with dementia with aggression and had a BIMS score of 5/15, indicating severe cognitive impairment. The construction foreman later sent an email on 08/22/25 elaborating that the construction staff had previously heard crying and pleas for help from Resident #1’s room and, upon approaching, believed they saw a staff member striking an elderly wheelchaired patient. In the same email, the foreman reported that on 08/20/25 at approximately 2:25 pm, they again heard crying, pleas for help, and noises resembling slapping from Resident #1’s room and felt strongly that someone in the room was being assaulted. At 2:50 pm that day, the foreman informed a facility staff member in the parking lot about what they heard and what had been reported days earlier. During interviews, the DON identified the alleged perpetrator as a private duty assistant hired by Resident #1’s family and stated that the facility did not have any human resources records for this individual, including abuse training, background checks, or licensing information. The DON also stated that the facility’s investigation did not include separate, facility-conducted interviews with each of the construction staff, demonstrating that the allegation of physical abuse was not thoroughly investigated.
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