Failure to Protect Residents from Physical Abuse and Inadequate Abuse Investigation
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, despite having a policy in place to prevent such incidents. In one instance, a resident entered another resident's room and struck her on the shoulder with a shoe, an event witnessed by a CNA. The affected resident reported feeling afraid and stated that the perpetrator had previously thrown a pitcher of water at her and repeatedly entered her room, even after a lock was placed on the bathroom door. The administrator did not conduct an abuse investigation or notify the State Agency, despite being informed of the incident and the resident's fear. Documentation and interviews confirmed that the incident was witnessed and reported to facility leadership, but no formal investigation was initiated. In a separate incident, the same resident was observed grabbing another resident's hair and attempting to take her walker. This event was witnessed by an LPN, who documented the incident and reported it to the administrator and DON, identifying it as potential abuse. However, the administrator did not immediately begin an investigation or report the incident to the State Agency. Both incidents demonstrate a failure to follow facility policy and regulatory requirements for investigating and reporting allegations of abuse, leaving residents unprotected from further harm.