Failure to Protect Residents from Abuse and Inadequate Reporting of Resident-to-Resident Incidents
Penalty
Summary
The facility failed to protect residents from physical and sexual abuse by other residents, as evidenced by multiple documented incidents involving residents with severe cognitive impairment. One male resident with dementia, anxiety, and depression repeatedly exhibited aggressive and violent behaviors toward a female resident with similar cognitive impairments. These behaviors included shoving, hitting, ramming a wheelchair into the female resident, and violently shaking her. Staff intervened to separate the residents during these incidents, but the events were not reported as abuse allegations to the state agency as required. Documentation and interviews revealed that staff and management were aware of the incidents, but the events were treated as personal issues between residents with dementia rather than as reportable abuse, contrary to facility policy and regulatory requirements. Further review of records and staff interviews indicated that the aggressive resident's behaviors were ongoing and escalating, with staff frequently attempting to redirect and separate the residents. Despite repeated reports from CNAs to supervisors and management, there were no changes in interventions beyond attempts at separation, and the incidents were not properly investigated or reported. The facility's abuse coordinator and DON acknowledged in interviews that the incidents should have been reported as abuse allegations but were not, and that this was a failure to follow required procedures. Additionally, documentation of the incidents was incomplete, and some staff were instructed not to use terms like "violent" in their reports. A separate incident involved a male resident with severe cognitive impairment who was observed fondling the breasts of a nonverbal female resident with dementia. Multiple staff members witnessed the event, separated the residents, and were instructed to keep them apart in the future. However, the incident was not reported to the abuse coordinator or state agency, and no investigation or incident report was completed. The facility's abuse policy defined such contact as sexual abuse and required immediate reporting and investigation, but this did not occur. The failure to report and investigate these incidents resulted in a lack of protection for vulnerable residents and a violation of their right to be free from abuse.