Failure to Protect Residents from Abuse and Inadequate Staff Response
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. Several residents with cognitive impairments, psychiatric disorders, and behavioral disturbances were involved in physical altercations with each other. In one instance, a resident with paranoid schizophrenia and a history of combative behavior was observed striking a roommate, who had dementia and was identified as a wanderer. The care plans for these residents noted their behavioral risks, but conflicting documentation was found regarding their behaviors and interventions. Staff witnessed and documented physical altercations, and residents were found to have entered each other's rooms, leading to further incidents of aggression and distress. In another case, a resident with dementia and behavioral disturbances was reported by another resident to have been verbally abused by a nurse aide during the night shift. The nurse aide was overheard yelling at the resident to "shut up and be quiet" multiple times. Statements from staff and residents confirmed the occurrence of loud, inappropriate, and aggressive interactions between the nurse aide and both residents and other staff members. The nurse aide was also reported to have yanked a resident's wheelchair and made demeaning comments in the presence of the resident and others. These actions were witnessed by staff and reported by residents, but there was a delay in reporting the abuse to facility leadership, and the staff member was not immediately removed from the unit as required by facility policy. Documentation and interviews revealed that the facility's staff did not consistently follow established protocols for monitoring, redirecting, and protecting residents with known behavioral risks. There were lapses in communication and reporting among staff regarding incidents of abuse and altercations. The facility's failure to implement and adhere to its abuse prevention policies resulted in residents being subjected to physical and verbal abuse, as well as emotional distress, without timely and appropriate intervention.