Failure to Investigate, Prevent, and Report Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to investigate, prevent, and correct repeated willful abuse by one resident against multiple other residents. Despite multiple documented incidents of physical and sexual abuse, as well as aggressive and threatening behaviors, the facility did not conduct thorough investigations, did not collect witness or staff statements, and did not implement effective interventions to protect residents from further harm. The facility also failed to accurately and timely report these incidents to the state agency as required by their own abuse and neglect policies, with several reports missing, delayed, or incomplete. The resident responsible for the abuse had a history of aggressive behaviors, substance use, and noncompliance with facility rules, including multiple instances of physical aggression, threats, and inappropriate conduct toward both residents and staff. Despite this, the care plan for the resident was minimally updated, and interventions such as increased supervision were rarely implemented and not sustained. The facility allowed the resident to move freely within the facility and to be placed with vulnerable roommates, resulting in repeated abuse incidents, including physical assaults and sexual abuse, some of which were substantiated only after police involvement. Victims included residents with significant cognitive and physical impairments, such as one who was dependent on staff for all activities of daily living and had severe cognitive impairment. Staff and resident interviews confirmed that the abusive resident was widely known to be violent, yet the facility did not take adequate steps to protect other residents or to follow their own policies for abuse prevention and reporting. Documentation and interviews revealed a pattern of unsubstantiated abuse allegations, lack of follow-up, and insufficient protective measures, leaving residents exposed to ongoing harm.