Failure to Prevent and Address Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for a resident with moderate to severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia, experienced increased confusion and no longer recognized her male roommate, with whom she previously had a relationship. Despite repeated expressions of fear and discomfort about her roommate, staff did not recognize these as possible allegations of abuse or neglect, nor did they investigate or intervene appropriately. The resident was observed repeatedly asking to leave, expressing fear of the roommate, and refusing to be in the same room or sit with him, yet staff continued to redirect her without addressing her underlying concerns or reassessing the appropriateness of the cohabitation arrangement. Progress notes and staff interviews revealed that the resident's confusion and distress persisted over several days, with staff documenting her statements about a 'creepy man' in her room and her refusal to be left alone with him. Despite these clear indications of psychosocial harm and potential neglect, there was no care plan addressing the cohabitation or relationship, and no assessment of the resident's capacity to consent to the relationship. Staff, including LVNs, the ADON, and the DON, failed to recognize the situation as a possible allegation of abuse or neglect, and did not report or protect the resident from further psychosocial harm. The facility also lacked a policy regarding resident capacity or consent for relationships and did not have procedures in place to assess or document consent when a resident's cognitive status changed. Interviews with staff and leadership confirmed that concerns about the resident's safety and consent were not escalated or addressed in a timely manner. The DON and Executive Director were unaware of the specific language used in progress notes indicating fear and discomfort, and there was no investigation or intervention until the situation was identified as Immediate Jeopardy by surveyors. The facility's failure to identify, report, and intervene placed the resident at risk for continued psychosocial harm and did not ensure her right to be free from abuse, neglect, and exploitation.