Failure to Prevent Resident-to-Resident Physical Abuse and Administrator Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident and another resident from verbal abuse by a staff member. One resident with multiple sclerosis and epilepsy, cognitively intact per a recent MDS, reported that approximately three weeks prior she was in the day room when another resident, who appeared intoxicated and had an open can of beer, choked her and then slapped her left arm hard enough to leave red marks. On the date of the incident, a RN passing medications just outside the day room heard a slap-like sound and the resident say “ouch,” then found the alleged aggressor in a wheelchair next to the resident and observed mild redness on the resident’s left upper arm. A CNA in the day room also heard a slapping noise and the resident call out, then turned and saw the alleged aggressor sitting next to her. The facility’s investigation substantiated resident-to-resident physical abuse based on the aggressor striking the resident’s left upper arm, though the choking allegation could not be substantiated. The resident alleged that the aggressor had been intoxicated and that he grabbed the front of her neck with one hand, making her unable to breathe, and then slapped her arm. The aggressor’s medical record showed moderate cognitive impairment on the BIMS, and he later acknowledged that he “smacked” the resident’s arm, stating he had been drinking beer at a family member’s house before being dropped off at the facility and did not remember the incident, but understood from others that it was an open-hand smack. The facility’s investigation documented that he appeared intoxicated at the time, had an open can of beer in his wheelchair, and had been watching the resident talk to another male resident, which he reportedly did not like, before approaching her. Staff present in or near the day room did not prevent the physical contact, and the abuse occurred in a common area while the aggressor was in possession of alcohol and visibly intoxicated. The deficiency also includes an incident of verbal abuse toward another resident by the former Nursing Home Administrator (NHA). This resident, with chronic diastolic heart failure, diabetes, and unspecified dementia and severe cognitive impairment per a recent MDS, was in his room with a wallet that staff believed belonged to another resident. During an attempt by staff, including the former NHA, Social Services Assistant, and Scheduler, to address the wallet issue, the resident became upset, hollering, swearing, and insisting the wallet and money were his. Multiple staff witnesses reported that the former NHA raised his voice, got in the resident’s face, pointed at him, and called him a “mother f**ker” after the resident swore at him, while the resident later recalled that the man involved swore and used “cussing words” toward him. The facility’s investigation determined that the wallet was in fact the resident’s, and staff accounts consistently described the former NHA’s use of profanity and raised voice toward the resident during the interaction.
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