Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from abuse, including sexual, physical, and verbal abuse, as evidenced by multiple incidents involving both staff and residents. In one incident, a resident with severely impaired cognition and no capacity to consent was found in their room with another resident who was nude from the waist down and caressing the first resident's hip and thigh. The staff assigned to these residents were unaware of the history of sexually inappropriate behaviors by the perpetrating resident, and the facility had not communicated these behaviors or implemented adequate interventions to ensure supervision and prevent such incidents. The incident was not reported to the State Agency until several days later, after the LPN who discovered the situation resigned and cited the unreported sexual assault as a reason for resignation. The facility's investigation did not include thorough documentation or interviews to clarify the nature of the incident, and staff were unclear on the required level of supervision for the resident with a history of inappropriate behaviors. Additional incidents included physical abuse between residents. In one case, a resident with severe cognitive impairment and a history of aggressive behaviors struck another resident in the back of the head multiple times. Staff who witnessed the event intervened to separate the residents, but the incident was still classified as physical abuse. In another case, a resident with a history of behavioral issues physically assaulted their roommate, resulting in both residents sustaining injuries. The facility's records indicated that both residents were evaluated and monitored following the incident, but the underlying behavioral risks had not been adequately addressed to prevent the altercation. The facility's policies required ongoing oversight, supervision, and individualized care planning for residents with behavioral symptoms that might lead to conflict or abuse. However, the survey found that these policies were not effectively implemented. Staff were not consistently informed of residents' behavioral risks, care plans did not include specific interventions to prevent residents from entering others' rooms, and there was a lack of clear documentation and communication regarding supervision requirements. These failures resulted in multiple residents experiencing or being at risk for abuse, and the facility was cited for noncompliance with federal regulations regarding freedom from abuse, neglect, and exploitation.