MOSES LAKE, WA- LAKE RIDGE CENTER

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45939

Based on interview and record review, the facility failed to protect the residents’ right to be free from physical abuse by staff for 1 of 3 residents (Resident 1) reviewed for abuse. This deficient practice placed residents at risk for further abuse and potential injuries.

Findings included .

Review of the facility policy titled, Abuse Prohibition, revised 05/01/2022, showed the facility prohibited the abuse and/or mistreatment of all residents. Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of dementia (a syndrome that causes a decline in cognitive abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), malnutrition (lack of proper nutrition caused by not eating enough), and anxiety (a feeling of fear, dread, and uneasiness). Review of the comprehensive assessment dated [DATE] showed Resident 1 had severe cognitive impairment, required the assistance of one person for dressing, toileting, bathing, and was independent with walking.

Review of the facility’s preliminary investigations dated 08/12/2024, for incidents involving Resident 1 on 08/08/2024 and 08/09/2024, showed Resident 1 had been exhibiting an increase in wandering behaviors and required frequent staff redirection.

The facility investigation for the incident on 08/09/2024 at 12:00 AM, showed Staff C, Registered Nurse (RN), pushed Resident 1, while attempting to redirect Resident 1 out of another resident’s room, causing Resident 1 to fall to the floor. Statements from Staff D, Nursing Assistant (NA), Staff E, NA, and Staff F, Licensed Practical Nurse (LPN) showed Staff C stated they pushed Resident 1 in response to Resident 1 hitting them in the chest. The investigation showed Staff C refused to be interviewed or to provide a statement regarding the incident. The investigation substantiated abuse against Resident 1 by Staff C. Review of the medical record showed a nursing Progress Notes (PN) entry by Staff C, dated 08/09/2024 at 12:14 AM (14 minutes after the incident), documenting a phone conversation between Staff C and a Resident Representative (RR) for Resident 1, and the RR stated they were aware Resident 1’s .escalating behaviors may need extra force.

Review of the document titled Contingent Staff Performance/Conduct Investigation Form, dated 08/09/2024 showed an incident of abuse by Staff C had been substantiated and the action taken was termination of employment.

During an interview, on 08/12/2024 at 1:40 PM, Staff B, Director of Nursing, stated based on the
investigation, Staff C should not have been on the floor with residents as their shift had ended at 10:00 PM. Staff B stated physical force was never acceptable toward a resident, especially from a staff member. Staff B stated Staff C did not follow facility policy or nursing standards of practice when dealing with Resident 1’s dementia and behaviors, and abuse of any kind resulted in immediate termination of employment.