Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in two residents experiencing verbal and physical abuse from another resident. One resident, who had a history of mental health diagnoses including Bipolar Disorder, Major Depressive Disorder, and paranoia, threatened to stab her roommate. This threat was reported to staff, but no immediate investigation or protective measures were initiated at that time. The care plan for the resident making threats noted paranoia, but there was no documentation of interventions or follow-up after the threat was reported. A few days later, the same resident entered another resident's room and physically assaulted her with a pole-like object, causing injuries that required hospitalization. The assaulted resident suffered an eye injury, bruises, and abrasions. Staff responded to the incident by intervening and calling emergency services, but prior to the assault, there were documented behavioral issues and escalating conflicts between the involved residents that were not adequately addressed. The care plan for the assaulted resident did not address the incident or provide interventions for her safety. Interviews with staff and the administrator revealed that the facility was aware of ongoing behavioral issues and conflicts among the residents, including previous threats and arguments. However, there was a lack of timely investigation, documentation, and implementation of protective measures following reports of threats and escalating behaviors. The administrator acknowledged that no safe surveys or investigations were conducted after the initial threat, and that staff had become conditioned to the aggressive resident's behavior, failing to take appropriate action to prevent further harm.