Failure to Prevent Abuse and Neglect Among Residents
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by several incidents involving both resident-to-resident aggression and inadequate supervision. In one case, a resident with severe cognitive impairment and a history of physical and verbal aggression was taken off 1:1 supervision, which led to an altercation where this resident entered another resident's room and physically assaulted both the resident and a CNA. Staff interviews confirmed that the aggressive resident was difficult to redirect and that the incident resulted in physical contact, though no injuries were noted. The care plan for this resident had previously identified the need for close supervision due to safety concerns, but this intervention was not maintained at the time of the incident. Another incident involved a cognitively intact resident who was physically assaulted by a resident with severe dementia and a history of wandering and aggression. The aggressive resident entered the other resident's room, took personal belongings, and struck the resident multiple times when confronted. Staff interviews and documentation indicated that the aggressive resident was sometimes redirectable but could become combative, and that interventions such as frequent checks and behavioral documentation were in place. However, these measures did not prevent the physical altercation from occurring. Additionally, the facility failed to ensure the safety of a resident with Parkinson's disease and moderate cognitive impairment during an activity where hot coffee was served. The resident, who required a non-spill cup and typically used a straw due to tremors, was given an open cup without a straw and was not adequately supervised. As a result, the resident spilled hot coffee on herself, sustaining a partial thickness burn. Staff interviews revealed inconsistent knowledge and implementation of the resident's care needs, and the care plan lacked specific interventions to prevent burns, despite identifying the risk.