Failure to Protect Residents from Abuse and Inappropriate Use of Mechanical Lift
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by both other residents and a staff member. Several incidents were documented in which residents with cognitive impairments and behavioral issues engaged in physical altercations. In one case, a resident with severe cognitive impairment and behavioral symptoms pushed another resident, resulting in a fall and injury. Staff interviews confirmed that the residents involved had a history of wandering and aggression, and that staffing levels were low, with only one aide and one nurse on the night shift, making supervision and intervention challenging. Another incident involved a resident being physically assaulted by a peer who accused him of theft. The staff responded quickly to separate the residents, and no physical harm was reported in this case. However, the facility's documentation and staff interviews indicated that the resident who initiated the altercation had escalating behaviors, including a subsequent arrest for staff assault, and required psychiatric care and one-to-one observation upon return to the facility. Additionally, a staff member was observed using a mechanical lift to keep a resident suspended above his bed, allegedly to prevent him from getting out of bed. Witnesses reported the staff member yelling at the resident and expressing frustration, while the staff member claimed he was changing bed linens and waiting for assistance. The facility's investigation confirmed that the use of the lift was inappropriate and did not meet the expected standards of care, as the resident was left in the lift as a means of control rather than for a legitimate care purpose.