Failure to Protect Residents from Abuse by Staff and Peers
Penalty
Summary
The facility failed to ensure that three residents were free from abuse, resulting in two separate incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a male resident with severe cognitive impairment and a history of anxiety disorder and vascular dementia was subjected to emotional and mental abuse by a CNA. Video footage showed the CNA antagonizing the resident, including placing her hand on his knee for an extended period while verbally confronting him about his language and behavior. The resident, who was dependent on staff for activities of daily living and had a care plan addressing behavioral issues, was observed to be verbally aggressive, but the CNA escalated the situation by engaging in a prolonged argument and physical contact that was not necessary for care. The CNA admitted to correcting the resident and acknowledged that her actions were inappropriate. In the second incident, two male residents, one with moderate cognitive impairment and a history of bipolar disorder and dementia, and the other with diagnoses including anxiety disorder and schizoaffective disorder, were involved in a verbal and physical altercation. The altercation began when one resident verbally abused the other by repeatedly calling him derogatory names, despite being asked to stop. This provoked the second resident to physically strike the first resident in the face. The incident was witnessed by a speech and language therapist, who intervened to separate the residents. Both residents had no prior history of physical or verbal behaviors towards others as documented in their assessments, and both were assessed with no injuries following the incident. Both incidents were identified as past noncompliance, with the facility having already addressed the issues before the investigation began. The failures in these cases involved staff engaging in antagonistic and abusive behavior towards a resident, as well as inadequate prevention of resident-to-resident abuse, resulting in emotional, mental, and physical harm. The events placed the affected residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.