Failure to Prevent Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by three substantiated incidents involving both resident-to-resident and staff-to-resident abuse. In two separate events, one resident physically assaulted two other residents on different occasions, resulting in both victims sustaining injuries that required emergency room evaluation. Witnesses, including LPNs and GNAs, confirmed that the assaults were unprovoked and led to falls and physical harm. The facility's investigations substantiated these incidents through staff interviews and medical record reviews. In a separate incident, a nurse was observed by a family member slapping a resident with dementia on a locked unit. The family member, who had a history of visiting the facility, reported the abuse to staff, and the nurse was subsequently asked to leave and terminated after the allegation was substantiated. The resident involved in this incident no longer resided at the facility. The Director of Nursing confirmed the findings of the investigation and the credibility of the witness.