Failure to Protect Resident From Physical Abuse and Corporal Punishment by LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident on the Alzheimer’s unit from physical abuse and corporal punishment by an LPN. According to staff interviews and facility documentation, an LPN smacked the resident’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Multiple staff, including a social worker, another LPN, and a nurse aide, reported that they viewed video footage of the incident and confirmed that the LPN did in fact smack the resident’s hand. One LPN and the initial abuse report noted discoloration to the resident’s hand following the incident. The incident occurred on the facility’s Reflections Hall, identified as the Alzheimer’s unit, and the reasonable person concept was applied to determine that an average person would experience psychosocial harm from being smacked in a healthcare setting. The facility’s own Abuse, Neglect, Exploitation policy required deployment of trained and qualified staff, room or staffing changes as needed to protect residents from alleged perpetrators, analysis of why abuse occurred, changes to care provisions to protect residents, staff training on changes made, and reporting of licensed staff suspected of abuse to their licensing board. Despite the policy and the substantiated finding of abuse and use of corporal punishment, the LPN involved in the incident was later found to be reinstated and working again on the Alzheimer’s unit. The DON confirmed that the LPN had not been reported to the LPN licensing board for the substantiated abuse and that required abuse training had not been provided prior to the LPN’s return to work. These actions and inactions demonstrate the facility’s failure to ensure the resident was free from physical abuse and to follow its own abuse prevention and response policies.
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