Staff-to-Resident Abuse Following Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by staff. Facility policy on abuse and neglect required staff to identify, assess, care-plan, and monitor residents with behaviors that might lead to conflict, including those with aggressive behaviors, self-injurious behaviors, communication disorders, or total dependence on staff, and to monitor for early warning signs or changes that could trigger abusive behavior. The resident involved had diagnoses including violent behavior, dementia, depression, mood disorder, anxiety, and conduct disorder. A care plan and quarterly assessment documented that the resident was moderately impaired for daily decision-making and had the potential to demonstrate behaviors such as yelling out, swinging at staff and residents, cussing, and making racial slurs toward staff. An incident report documented that the resident threw soda on a CNA, who then threw a drink back into the resident’s face. A receptionist who witnessed the event stated the resident, seated near the CNA in a common room, suddenly threw a can of soda at the CNA, and the CNA immediately jumped up and threw the soda can back into the resident’s face, then walked down the hall saying staff should “get” the resident and using explicit language. The incident was reported to the administrator. In a later phone interview, the CNA stated the resident had called them racial names and thrown a drink that hit a bowl in the CNA’s hand, spilling drinks on the table and splashing on the resident, which led the resident to yell that the CNA had thrown a drink at them. The resident later stated they had not had a staff member throw a drink at them or abuse them. Despite these differing accounts, the documented staff action of throwing a drink back at the resident constituted abuse and demonstrated the facility’s failure to ensure the resident was free from abuse.
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