Failure to Protect Residents from Abuse by Peers, Staff, and Family
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical abuse by other residents, staff, and a family member. Several incidents were documented where residents with cognitive impairments, such as Alzheimer's disease, dementia, and schizophrenia, were involved in altercations resulting in physical harm. For example, one resident was slapped by another after being startled awake, and another was struck in the face by a peer who believed his foot was at risk. In another case, a resident was hit on the cheek by a fellow resident during a dining room altercation. These incidents occurred despite care plans and staff awareness of the residents' behavioral risks and cognitive limitations. Staff also failed to prevent abuse by facility personnel. In one incident, a CNA slapped a resident on the back of the hand during a transfer when the resident became combative. The event was witnessed by another CNA, and the action was acknowledged as abuse by the facility's administrator. The resident involved was dependent on staff for most activities of daily living and had a history of combative behavior, which was documented in her care plan. The staff member involved was suspended and subsequently terminated, but the incident itself demonstrated a lapse in protecting the resident from staff-initiated abuse. Additionally, the facility did not prevent abuse by a family member. In one case, a resident with severe cognitive impairment was slapped in the face by a family member during a dispute over discharge against medical advice. The incident resulted in visible injury and required intervention by staff and law enforcement. The resident expressed a desire to remain in the facility and not leave with the family member, but the abuse occurred before the situation was de-escalated. These failures to prevent abuse placed residents at risk of physical harm, mental anguish, or emotional distress, as documented in the report.