Failure to Prevent and Report Resident Abuse and Neglect
Penalty
Summary
Facility staff failed to prevent repeated willful abuse and neglect among residents, as well as by staff, resulting in multiple incidents of physical and sexual abuse, neglect, and failure to protect vulnerable individuals. One resident with severe cognitive impairment and total dependence for activities of daily living was assaulted by his roommate, who had a documented history of aggressive and abusive behaviors toward other residents. Despite multiple prior incidents, the facility did not implement ongoing supervision or effective interventions to prevent further abuse, nor did they accurately or promptly report or investigate these incidents as required by policy and regulation. Documentation and care plans failed to reflect the true extent of the resident's behaviors, and staff did not take adequate steps to protect new or existing victims from further harm. Another resident was physically assaulted by a roommate with a known history of agitation and psychosis, resulting in a contusion and hospital evaluation. The facility was aware of the aggressor's psychiatric history and medication needs, yet failed to prevent the assault. The incident was reported to authorities and agencies, and the residents were separated after the event, but the initial failure to protect the victim from a known risk was evident. The aggressor was later discharged, but the victim remained upset about the incident. Additionally, a resident reported neglect and rough treatment by CNAs, including being left without incontinence care for an entire night and experiencing rude and rough handling during care. The resident felt helpless and unprotected, and reported the incidents to the DON, who acknowledged the issue but did not initially treat it as an allegation of abuse or neglect. The facility's own policy required investigation and protection in such cases, but these steps were not taken in a timely or effective manner.