Failure to Prevent Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including physical, verbal, and sexual abuse, as well as neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident interactions. In one case, a cognitively intact resident reported that a severely cognitively impaired resident inappropriately touched her breast on two occasions during hugs, with the second incident perceived as intentional. The resident stated she would no longer allow the other resident to hug her, and no further incidents were reported. Another incident involved a severely cognitively impaired resident who was verbally threatened with sexual assault by another cognitively intact resident during care provided by CNAs. The threatening resident made repeated inappropriate comments and threats in the presence of staff. Additionally, a physical and verbal altercation occurred between two cognitively intact residents in the courtyard, where racial slurs were exchanged, and both residents engaged in physical aggression, resulting in one resident being slapped and the other being hit in the face. Both residents declined to press charges after the incident was reported to the police. A separate event involved an agency CNA who was overheard by an LPN yelling at a cognitively intact resident, instructing her to roll over by herself in a loud and inappropriate manner. The LPN intervened, removed the CNA from the room, and escorted her out of the facility. The resident denied any physical harm but confirmed the verbal abuse. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was confirmed that these incidents constituted failures to prevent and prohibit all types of abuse as required.