Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in two separate incidents involving three residents. In the first incident, a female resident with a history of PTSD, anxiety disorder, and schizophrenia was inappropriately touched by a male resident during a smoke break. The male resident, who had diagnoses including metabolic encephalopathy and personality disorder, was witnessed by staff touching the female resident's face, hair, and breast area without her consent. The female resident expressed that she did not want to be touched, and staff intervened immediately after witnessing the event. The incident was reported to the police, and both residents were assessed by medical and psychiatric staff. The female resident later reported feeling angry and fearful as a result of the incident. In the second incident, a male resident with severe cognitive impairment, schizophrenia, and Alzheimer's disease was involved in a physical altercation with the same male resident who had previously committed the inappropriate touching. The altercation occurred in the early morning hours and was unwitnessed by staff. The cognitively impaired resident was found with injuries including skin tears, a raised area on the forehead, and a laceration to the upper lip. The male resident involved in both incidents admitted to hitting the other resident, stating he was defending himself after the other resident entered his room. Staff interviews and documentation indicated that the cognitively impaired resident had a history of wandering into other residents' rooms due to his dementia. Both incidents were confirmed through observation, interviews, and record reviews. The facility's failure to prevent these incidents resulted in residents being exposed to sexual and physical abuse. The events were not prevented despite the known behavioral and cognitive issues of the residents involved, and the incidents were only addressed after they occurred. The survey identified these failures as past noncompliance, with Immediate Jeopardy beginning on the date of the first incident and ending after the second incident.