Failure to Protect Residents from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by two separate incidents involving four residents. In the first incident, a resident with major depressive disorder, unspecified psychosis, and dementia, who required substantial assistance with daily activities, was physically and verbally abused by another resident in their shared room. The aggressor, who also had significant medical conditions and required assistance, was observed by a CNA making a fist and striking the other resident in the lower abdomen after being woken up, followed by the use of profanities. Eyewitness accounts and documentation confirmed the physical and verbal abuse. In the second incident, two residents with cognitive impairments and dependencies for care were involved in a physical altercation during lunch in the staff dining room. One resident, after a verbal argument over a nutritional supplement, was pushed by another resident with an open hand on the shoulder, nearly causing a fall. Staff present intervened to prevent injury. Eyewitness statements and facility records substantiated that physical contact was made with enough force to potentially cause harm, and the incident was classified as abuse by the facility's DON. Both incidents were substantiated through interviews, eyewitness accounts, and review of facility records, including admission records, MDS assessments, incident notes, and abuse investigation forms. The facility's own policies prohibit all forms of abuse and require staff to protect residents from abuse by anyone, including other residents. Despite these policies, the facility did not prevent or adequately protect the residents from being subjected to physical and verbal abuse by their peers.