Failure to Protect Residents from Abuse by Staff and Other Residents
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in substantiated incidents involving both staff-to-resident and resident-to-resident abuse. One resident, who had multiple diagnoses including hypertensive heart and chronic kidney disease, morbid obesity, major depressive disorder, anxiety disorder, and unspecified dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. This resident reported that a CNA was angry, aggressive, and rough during care, and that the CNA threw a snack at her. Multiple residents confirmed that the CNA was physically aggressive and displayed an angry demeanor toward them. Documentation and interviews revealed that the resident did not feel safe when cared for by this staff member, and the CNA was described as verbally rude and rough with care by several residents and staff members. Another incident involved a resident with metabolic encephalopathy, anxiety disorder, and muscle weakness, who exhibited wandering behaviors and attempted to help other residents, making her difficult to redirect. This resident entered another resident's room, leading to a physical altercation where the second resident, who had severe cognitive impairment and a history of behavioral problems including aggression, grabbed the first resident's arm and would not let go, causing a scratch and bruise. Staff witnessed the incident and confirmed that the resident who initiated the physical contact had a history of aggression and was difficult to redirect. The care plan for the wandering resident did not address her wandering behavior, despite repeated documentation of her entering other residents' rooms and interacting with them in ways that led to conflict. Facility documentation, including care plans, nursing notes, and staff interviews, confirmed that both incidents were substantiated as abuse. The facility's policy defined abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and included both staff-to-resident and resident-to-resident altercations. The failure to prevent these incidents demonstrated a lack of effective measures to protect residents from abuse by staff and other residents.