Failure to Protect Residents from Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, specifically involving two residents with histories of aggressive and inappropriate behaviors. One resident, with severe cognitive impairment and a history of mood disorders and aggression, was involved in multiple incidents, including a physical altercation with a roommate and an episode of inappropriate sexual behavior toward another resident. Despite documentation of these behaviors in progress notes and care plans, the care plan did not address sexually inappropriate behavior, and interventions for aggressive conduct were inconsistently implemented or documented. Staff interviews revealed a lack of awareness and follow-up regarding the sexual incident, and the psychiatric provider was not notified of the event, missing an opportunity for timely intervention. Another resident, with moderate cognitive impairment and a history of depression, suicidal behavior, and aggression, was also involved in the physical altercation. This resident had previously exhibited verbal and physical aggression toward roommates and staff, including threats and throwing objects. The care plan and psychological notes did not address these behaviors or the altercation, and there was no evidence of comprehensive behavioral interventions or adjustments following repeated incidents. Staff interviews indicated that both residents were known to be incompatible as roommates due to their aggressive tendencies, yet they were placed together, leading to a physical altercation resulting in injury and an ER visit. The facility's investigation and documentation of the incidents were incomplete. The Provider Investigation Report lacked staff statements and did not indicate whether law enforcement or the Ombudsman were notified. Staff interviews revealed inconsistent reporting and follow-up on behavioral incidents, and there was no evidence of increased supervision or staffing adjustments after the altercation. Facility policies required immediate safety strategies and thorough investigations, but these were not fully implemented, leaving residents at risk of harm from abuse and neglect.