Failure to Protect Residents from Abuse, Neglect, and Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse, implement interventions to protect residents from potential physical abuse, and prevent neglect. Multiple residents with intact cognition were involved in a series of verbal altercations, including threats of physical harm. One resident made repeated verbal threats to another, including threats to set them on fire and have them shot, while another resident responded with threats of physical violence. These altercations escalated to the point where one resident produced a knife and attempted to jab it at a nurse, demonstrating a clear risk of physical harm. Documentation revealed that, although the facility reported separating the involved residents and placing them on one-on-one (1:1) supervision, there was no consistent documentation to confirm that 1:1 supervision was provided for each shift during the investigation. Additionally, care plans for the residents involved were not updated to reflect the interventions taken in response to the incidents. Staff interviews indicated a lack of clarity regarding who was responsible for 1:1 supervision during certain shifts, and there was no evidence that all staff had received the required in-service training on abuse, neglect, and misappropriation as claimed in the facility's incident report. Another incident involved a resident who reported being treated roughly and spoken to harshly by a CNA, including being told they would only be changed every two hours and experiencing pain during care. The resident expressed feeling unsafe with the CNA, and the facility's investigation led to the CNA's termination. However, staff interviews indicated that not all staff were aware of the incident or the findings of the investigation. The facility's failure to provide adequate documentation, update care plans, and ensure staff training contributed to the deficiencies identified by surveyors.