Failure to Prevent Recurrence of Abuse Allegations
Penalty
Summary
The facility failed to implement interventions to prevent the recurrence of abuse and neglect allegations for a resident who reported two separate incidents within a two-week period. The first incident involved the resident alleging that staff changed and dressed them without permission, despite the resident verbally refusing and expressing distress. The resident reported being held down by the wrists and forced to change their shirt, which they described as a violation of their rights. The second incident occurred under similar circumstances, with another staff member changing the resident's shirt without consent, even after the resident became combative and verbally objected. Interviews with staff confirmed that care was provided despite the resident's refusal, and the staff continued with the task after the resident expressed their wishes. The Director of Nursing acknowledged that while notes were added to the resident's care plan regarding these events, there were no actual adjustments made to the plan of care to address the resident's needs or to prevent future occurrences. This lack of intervention contributed to repeated allegations of abuse by the same resident.