Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with severe cognitive impairment and multiple medical conditions, including hemiparesis and dementia, was pushed by her roommate, who also had severe cognitive impairment and behavioral disturbances. This push caused the resident to fall, resulting in a wrist fracture, head abrasion, and a bump to the head. The facility's internal investigation documented that the resident was pushed, but ultimately concluded the abuse allegation was unsubstantiated, citing no actual allegation of abuse by either resident, despite clear evidence of physical harm resulting from the altercation. In the second incident, a cognitively intact resident with depression and anxiety reported feeling uncomfortable and fearful due to another resident's behaviors, which included staring, making inappropriate comments, and inappropriate touching. The resident filed a grievance about the behaviors, which led to her being moved to a different room. However, the resident who exhibited the inappropriate behaviors was later moved to a room directly across from the complainant, leading to further distress and self-isolation by the affected resident. The facility did not document the grievance or the subsequent conversations regarding the room changes, and staff were unaware of the full extent of the inappropriate behaviors reported, including the allegation of sexual touching. The facility's policies required all staff to identify and report abuse, and to take every precaution to prevent abuse by anyone, including other residents. Despite this, the facility did not adequately protect the residents involved from physical and sexual abuse, nor did it ensure that grievances and reports of abuse were properly documented and investigated. Staff interviews revealed a lack of awareness and follow-through regarding the reported incidents, and interventions to prevent further abuse were not implemented in a timely manner.