Failure to Protect Residents from Abuse and Inadequate Investigative Response
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including sexual and physical abuse, as well as neglect, as evidenced by several incidents involving both visitors and other residents. In one case, a resident with anoxic brain damage and severe cognitive impairment was subjected to repeated alleged sexual abuse by a visitor, specifically her boyfriend. Despite staff witnessing inappropriate touching on multiple occasions and the resident being unable to consent due to her condition, the facility did not implement timely or effective interventions to prevent further incidents. There were delays in restricting the visitor's access, and staff were not immediately educated on measures to keep the resident safe during ongoing investigations. Additionally, the facility failed to conduct a thorough and timely investigation, including not promptly interviewing the alleged perpetrator and not submitting required reports to the State Agency within the mandated timeframe. In another set of incidents, the facility did not adequately protect two residents from physical abuse by each other. One resident, who had a history of wandering and cognitive impairment, entered another resident's room, leading to a physical altercation. The facility's response and preventive measures prior to the incident were not detailed, but the event highlights a lack of effective supervision and interventions to prevent resident-to-resident altercations, especially among those with known behavioral risks. Additionally, a separate resident was not protected from physical abuse by another resident in two separate incidents. The report details that the facility's policies required immediate investigation and protective measures when abuse was suspected or reported, but these were not consistently followed. The documentation shows that the facility's actions and inactions, including delayed or insufficient interventions, lack of timely staff education, and incomplete investigations, directly contributed to the deficiencies cited by surveyors.