Failure to Protect Residents from Staff Abuse and Inadequate Response to Allegations
Penalty
Summary
The facility failed to protect residents from staff abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident with severe cognitive impairment, legal blindness, and multiple medical conditions was involved in an altercation with an LPN. The resident, who is known to startle easily and exhibit physical aggression due to her blindness, was at the nurse's station when she began touching the LPN's personal items. The LPN responded by grabbing the resident's hands, leading to a physical exchange where the resident bent the LPN's thumb. The situation escalated verbally, and after the resident spat on the LPN, the LPN retaliated by spitting in the resident's face. Multiple staff members witnessed the event, and the resident was observed wiping her face and expressing distress immediately after the incident. In the second incident, another resident with a history of respiratory and cardiac issues, as well as dementia and anxiety, reported being verbally abused by the same LPN. The resident, who was alert and oriented at the time of the interview, described being called derogatory names and being told her symptoms were imaginary. She documented these statements and reported feeling scared and upset. Several CNAs corroborated that the resident had reported being verbally mistreated and was visibly distressed, with one CNA stating the resident was crying. However, there was confusion and lack of clarity among staff and administration regarding the reporting and investigation of these allegations, with some staff stating they reported the abuse to supervisors, while others, including the DON and Administrator, denied receiving such reports or stated they were unable to investigate further due to lack of specific information. Documentation related to the grievances and follow-up was incomplete. A grievance form was filed by the resident regarding staff conduct, but it lacked specific details, and there was no evidence of consistent follow-up as indicated in the action plan. Progress notes and interviews revealed that the resident continued to express concerns about staff behavior, but the facility's documentation and response to these concerns were insufficient, with missing records of required follow-up meetings and unclear communication among staff regarding the allegations.