Failure to Assess Resident After Reported Staff Verbal and Physical Abuse
Penalty
Summary
The facility failed to assess and evaluate a resident following incidents of alleged verbal and physical abuse by a nurse aide, as required by its abuse policy. The resident, who had a diagnosis of Major Depressive Disorder and was documented as cognitively intact with a BIMS score of 15 on the January 5, 2026 MDS, reported that a nurse aide verbally, physically, and mentally abused them. The facility’s Abuse Policy-Prevention and Management, reviewed August 2025, required that upon receiving reports of physical or sexual abuse, the DON or designee immediately examine the resident, document findings in the clinical record, and ensure the nurse immediately notifies the physician and the resident or representative. Despite this policy, there was no documented evidence that a licensed nurse assessed the resident after a verbal abuse incident on February 21, 2026, or after a physical abuse incident on February 23, 2026. According to the facility’s investigation and staff interviews, the resident had complained that the nurse aide did not want to open doors or provide care and that the aide “always argue[s]” with them. On the day of the physical altercation, the Assistant DON reported that the resident approached her to complain about the aide, then began to wheel away when the aide said something in Spanish that upset the resident, prompting the resident to move toward the aide. The aide refused to move away when instructed, the resident grabbed the aide’s sweater collar, and the aide responded by placing a hand around the resident’s neck in a choke-hold position and then placing a hand on the resident’s face and pushing it, requiring the Assistant DON to intervene and separate them. The clinical record contained no documentation that the resident was examined by a licensed nurse or physician after this physical abuse incident, no evidence that a physician was notified, and no documentation that the resident was evaluated by a psychologist or provided emotional or psychological support after the verbal abuse incident.
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