Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including physical, sexual, and verbal abuse, as well as neglect, as evidenced by multiple incidents involving resident-to-resident altercations. Nineteen residents were identified as victims of abuse or neglect, with documented events such as groping, slapping, pushing resulting in injury, hitting with objects, and verbal aggression. In several cases, residents with known histories of behavioral disturbances and severe cognitive impairment engaged in aggressive acts against other residents, and the facility did not have adequate interventions or care plan updates to address these behaviors. Specific incidents included a resident being groped by another resident, a resident being pushed to the floor resulting in a hip fracture, and multiple instances of residents being hit, punched, or verbally abused by peers. Some residents had care plans that acknowledged their potential for aggressive behavior, but interventions were either not effective or not sufficiently implemented to prevent further incidents. In other cases, residents with a history of aggression did not have care plans that addressed these risks at all. Documentation revealed that staff were sometimes unable to intervene in time to prevent abuse, and in some cases, residents were not separated or monitored closely enough to prevent repeated incidents. The facility's incident logs and progress notes showed a pattern of recurring altercations, with some residents being involved in multiple incidents over time. Despite behavioral health consultations and medication adjustments, aggressive behaviors persisted, and the facility did not consistently update care plans or implement effective monitoring and supervision. The survey identified an Immediate Jeopardy situation due to the ongoing risk of abuse and harm to residents, and the facility remained out of compliance pending evaluation of the effectiveness of corrective systems.