Failure to Prevent Abuse and Neglect Among Residents and Staff
Penalty
Summary
The facility failed to protect residents from abuse and neglect in two separate incidents. In the first incident, a staff member engaged in a verbal altercation with a resident, during which both parties exchanged insults and profanity. The staff member escalated the situation by making a threatening statement towards the resident and using inappropriate language, including insults about the resident's mother. Multiple staff and resident interviews confirmed that the staff member had to be physically held back by other staff to prevent further escalation. The resident involved was cognitively intact and had a history of verbal aggression, but at the time of the incident, there was no physical contact or injury reported. In the second incident, two residents were involved in a physical altercation. One resident, who had a diagnosis of alcohol abuse and was under the influence at the time, became angry with their roommate for making noise early in the morning. The aggressive resident pushed the other resident to the floor and attempted to strike them, but missed. Staff intervened and separated the residents. The resident who was pushed had severe cognitive impairment but did not sustain any injuries and reported feeling safe after the incident. The aggressive resident admitted to consuming alcohol and had previously signed a behavior agreement to refrain from alcohol use and aggressive behavior. Both incidents were witnessed by staff and corroborated through interviews and documentation. The facility's policies required staff to prevent, identify, and report abuse, but in these cases, the staff member's actions and the resident-to-resident altercation were not prevented, resulting in violations of residents' rights to be free from abuse and neglect. The events were reported to the appropriate facility leadership and law enforcement, and the facility's failure to prevent these incidents constituted a deficiency.