Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. In one case, a resident with severe cognitive impairment and multiple comorbidities was bitten on the hand by another resident, resulting in injury. The incident was observed by staff, and the injured resident was found to have puncture wounds on the left hand. The biting resident was subsequently relocated, but the initial failure to prevent the altercation constituted a deficiency in protecting residents from abuse. Another incident involved a staff member physically abusing a resident with severe cognitive impairment and behavioral issues. The resident, who was known to wander and sometimes be combative, was struck in the face by a CNA after the resident allegedly grabbed the staff member. The abuse was witnessed by another CNA, who intervened and reported the incident. The staff member involved was terminated, but the event highlighted a lapse in ensuring residents were free from staff abuse. Additional deficiencies were identified in cases where residents with histories of aggression and cognitive impairment engaged in repeated altercations, resulting in physical injuries such as bruises and lacerations. In several instances, residents who were supposed to be under 1:1 supervision still managed to physically harm others, indicating that the supervision was inadequate. Facility documentation and interviews confirmed that these incidents were substantiated as abuse, and in one case, a staff member assigned to 1:1 supervision was terminated for neglect after failing to prevent an assault. The facility's actions and inactions in these cases failed to ensure residents were protected from all forms of abuse and neglect.