Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse by other residents, resulting in actual harm to two residents. In one incident, a resident with severe cognitive impairment and a history of wandering was physically assaulted by another resident, also with severe cognitive impairment and a history of agitation. The aggressor was observed by staff yelling at the victim for entering his room, then physically grabbing and throwing the victim to the floor. This resulted in the victim sustaining a fractured clavicle, a scalp laceration, and a knee abrasion. Prior to this event, there was a documented history of the aggressor displaying aggressive behavior toward other residents, including cursing, threatening, and physical aggression, but the records did not indicate what measures, if any, were implemented to keep the residents separated or to prevent further incidents. In a separate incident, a resident with severe cognitive impairment and a history of Alzheimer's disease was sexually abused by another resident with moderate cognitive impairment and a history of schizophrenia and inappropriate behaviors. The incident was discovered when the victim's roommate alerted staff after witnessing the perpetrator inappropriately touching the victim while she was in bed. The victim was unable to recall the incident due to her advanced dementia. The perpetrator was found in the room with his pants down and was escorted out by staff. The facility's records indicate that the perpetrator was placed under constant surveillance until he was discharged, and no further incidents were reported between these residents. Interviews with current facility leadership, including the Administrator, DON, and Social Service Director, revealed that they were not employed at the time of the incidents and were unable to provide information on what interventions or protective measures were implemented following the events. The facility's policy on abuse prevention emphasizes a standard of intolerance for abuse, neglect, and exploitation, but the documentation reviewed did not demonstrate that effective measures were taken to prevent recurrence or to protect residents from further harm at the time of the incidents.