Failure to Separate and Supervise Residents After Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by not separating, supervising, or monitoring after an incident involving another resident with a known history of delusions, severe cognitive impairment, and behavioral disturbances. The resident with dementia and major depressive disorder had a documented pattern of wandering, invading others' personal spaces, and exhibiting both verbal and physical aggression. On the evening in question, this resident entered her roommate's space, yelled, and struck her multiple times on the leg with a water bottle. The affected resident reported feeling unsafe and fearful, and stated that previous complaints to staff about similar behaviors had not resulted in any action. Despite being informed of the incident, the CNA and LVN who responded did not remove the aggressive resident from the shared room or provide additional supervision. The LVN did not consider the event to be abuse since there were no visible injuries, and left the residents unsupervised together after the incident. Other residents in the room also expressed fear and concern about the aggressive resident's behavior, noting a pattern of wandering and intruding into their spaces. The responsible party for the affected resident called the police due to concerns about the facility's lack of response. Interviews with facility leadership confirmed that the facility's policy requires immediate separation and supervision following allegations of abuse, but this was not followed. The DON and Administrator both acknowledged that the aggressive resident should have been moved and provided with one-on-one supervision after the incident. The facility's own policies and procedures, as well as federal and state regulations, guarantee residents' rights to be free from abuse and to be treated with dignity and respect, which were not upheld in this situation.