Failure to Protect Resident From Staff Altercation in Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment free from abuse when a physical and verbal altercation between two staff members occurred in a resident’s room and on the resident’s bed while the resident was present. The resident had been admitted with multiple serious medical conditions, including a displaced fracture of the right femur, COPD, DM2, HTN, pulmonary embolism with acute cor pulmonale, generalized muscle weakness, and a cognitive communication deficit. An MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment. Despite these vulnerabilities, the facility did not prevent staff from engaging in a violent confrontation in the resident’s immediate care environment. According to a police report, a CNA stated that an RN pushed him, and he pushed the RN into a resident room, where he punched her in the face and then restrained her on the ground. The RN reported that she had prior issues with the CNA and that on the night of the incident she observed him yelling in a patient’s room while on the phone with the DON. She stated that after she told him to leave the facility to take the call elsewhere, he approached and punched her multiple times in the face, dragged her by the collar into the resident’s room, and continued the assault on the floor next to the resident’s bed, including placing his knee against her chin and neck. The CNA, in his own account, acknowledged that the physical struggle moved into the resident’s room, that the RN climbed onto the resident’s bed while the resident was still in it and kicked at him, and that a bedside table with a water pitcher was pushed toward him during the altercation. The resident’s psychiatrist reported that the resident described being in bed when she was awakened by noise and feeling her bed move, and that she witnessed the two staff members engaging in a verbal and physical altercation. The psychiatrist stated the resident reported feeling frightened, depressed, anxious, and that she did not feel safe in the facility. The DON later learned that furniture in the resident’s room had been moved during the incident and that the resident was found wrapped in a blanket and being consoled by CNAs. The DON reported that the resident was very anxious and stated she heard loud voices and felt her bed being bumped. These events demonstrate that the facility failed to protect the resident from exposure to physical and mental abuse by not preventing or adequately controlling a staff-on-staff altercation that occurred in the resident’s room and on her bed while she was present.
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