Failure to Prevent, Report, and Investigate Resident Abuse and Neglect
Penalty
Summary
Facility staff failed to prevent repeated willful abuse, neglect, and theft involving multiple residents, including incidents perpetrated by both residents and staff. Despite clear evidence of ongoing aggressive and abusive behaviors by one resident, the facility did not implement effective interventions or supervision to protect other residents. The facility also failed to accurately and timely report abuse allegations to the state agency, did not conduct thorough investigations, and did not follow its own abuse and neglect policies. Documentation and staff interviews revealed that abuse incidents were either not reported, reported late, or not substantiated despite substantial evidence, and that residents were not protected from a known abuser. One resident with a history of aggressive and violent behaviors, including physical and sexual abuse, theft, and threats against other residents and staff, was allowed to move freely within the facility and was repeatedly placed with new roommates who subsequently became victims of abuse. This resident had multiple documented incidents of physical aggression, inappropriate touching, theft, substance use, and threats, yet the care plan and interventions were minimal and inconsistently applied. Supervision was only increased on two occasions, a year apart, and the resident continued to have access to vulnerable residents, including those with severe cognitive impairment and total dependence on staff for care. The facility's documentation and records were incomplete, with missing or inadequate investigation files, lack of witness or staff statements, and insufficient planning to prevent further abuse. Staff interviews confirmed awareness of the resident's behaviors, but most were agency staff unfamiliar with the ongoing issues. The facility's failure to implement its abuse prevention policy, protect residents from a known abuser, and ensure timely and accurate reporting and investigation of abuse allegations resulted in multiple residents being subjected to repeated abuse and neglect.