Failure to Prevent Abuse and Neglect of Residents
Penalty
Summary
The facility failed to protect residents from abuse and neglect in multiple instances involving three residents. In one case, a resident with functional quadriplegia and total dependence on staff for care reported that a night shift SRNA intentionally removed his call light device from the wall and inserted a plastic object into the port, rendering the call system unusable for the duration of the shift. The resident, who was able to make decisions regarding daily life tasks and communicate his needs, was left without access to the call system until the following day when a day shift SRNA discovered the issue and restored the device. The staff member involved admitted to removing the device due to a malfunction but failed to notify maintenance or the oncoming shift, and no work order was placed for repair. The resident did not experience further incidents with the call device after the event. In another incident, a resident with severe cognitive impairment physically struck another resident who had entered her room, resulting in a nosebleed for the visitor and an ankle injury for the aggressor. Both residents were immediately separated by staff, and the incident was witnessed by staff who responded to the altercation. The resident who was struck was confused but did not show signs of pain or fear, and the aggressor was assessed for injury. Both residents' families and appropriate authorities were notified, and psychosocial monitoring was conducted following the event. The facility placed a stop sign on the aggressor's door to prevent further incidents of wandering into her room. The facility's policies required screening of potential hires for abuse history, background checks, and staff training on abuse prevention and reporting. Despite these policies, the incidents occurred due to staff inaction, such as failing to ensure the call light was functional and not reporting or addressing the malfunction, as well as inadequate supervision that allowed a resident-to-resident altercation to occur. Interviews with staff and administration confirmed the sequence of events and the failure to follow established protocols to prevent abuse and neglect.