Failure to Report and Investigate Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, and exploitation for multiple residents with severe cognitive impairment. Several incidents involving resident-to-resident physical and sexual abuse were observed, documented, and reported by staff to supervisors, but these incidents were not reported to the state agency as required by facility policy. Specifically, a male resident with dementia repeatedly exhibited aggressive and violent behaviors toward a female resident, including shoving, hitting, ramming with a wheelchair, and violently shaking her. Despite staff interventions and documentation of these events, the incidents were not reported to the Director of Nursing (DON) or Nursing Home Administrator (NHA) as abuse allegations, and no thorough investigations were conducted. Staff were instructed by leadership not to use terms like "violent" in documentation, and the rationale given for not reporting was that both residents had dementia. Additionally, another male resident with severe cognitive impairment was observed and reported by staff to have engaged in sexually inappropriate behavior toward a female resident, including fondling her breasts in a group setting. Multiple staff members witnessed the incident, separated the residents, and reported the event to nursing staff. However, there was no evidence of an incident report or investigation, and the NHA and DON were unaware of the event until questioned during the survey. The facility's abuse policy defined such actions as sexual abuse and required immediate reporting and investigation, which did not occur. Interviews with staff, including CNAs, nurses, and the social worker, revealed a pattern of underreporting and lack of follow-through on abuse allegations, particularly when incidents involved residents with dementia. Staff reported escalating behaviors, frequent altercations, and emotional distress experienced by the victims, but these were not addressed according to policy. The failure to report and investigate these incidents resulted in potential ongoing abuse and emotional harm to vulnerable residents.