Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding resident protection, abuse reporting, and investigation following multiple incidents of verbal and physical abuse by one resident toward another. Despite repeated documentation of aggressive behaviors, including yelling, threats, and physical altercations, there was no evidence that these incidents were reported to the State Agency (SA) or Adult Protective Services (APS), nor that a thorough investigation was conducted. Staff and witness interviews confirmed that the abusive behaviors were ongoing and known to staff, yet no effective interventions or increased supervision were implemented to prevent further incidents. The residents involved had significant cognitive impairments, with one resident having a documented history of dementia, muscle weakness, and severe cognitive impairment, as indicated by a BIMS score of 00. The alleged perpetrator also had dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited paranoid and possessive behaviors toward another resident. Multiple behavior notes detailed a pattern of verbal aggression, threats, and physical altercations, including slapping and pushing, which were witnessed by staff and other residents. Despite these documented incidents, the facility did not take timely or adequate steps to separate the residents or provide increased monitoring to ensure safety. Interviews with staff revealed confusion and inconsistency regarding the reporting process for abuse, with some staff being instructed not to escalate or report incidents involving residents with cognitive impairment. The facility's own policy required immediate reporting and investigation of abuse allegations, regardless of the cognitive status of those involved, but this was not followed. Documentation showed delays in recording incidents and a lack of protective measures for the victim, resulting in continued exposure to abuse and psychological distress.