Failure to Protect Residents from Abuse and Inadequate Incident Response
Penalty
Summary
Multiple incidents occurred in which residents with severe cognitive impairment and a history of wandering were found in compromising situations with another resident, including being found in bed together without pants or with clothing removed and exposed. In several cases, staff or family members discovered the incidents, and the involved residents were separated and placed on increased monitoring. Despite these events, there was no documented evidence that a registered nurse assessed the residents immediately following the incidents, even when complaints of pain or signs of distress were present. Additionally, there was no documentation that the residents' families were notified of the incidents as required. Care plans for the residents involved were not updated to reflect the risk or occurrence of abuse or potential victimization, and interventions were limited to increased monitoring without addressing the underlying risks. Social work and psychosocial assessments were not documented following the incidents, and medical providers were not consistently notified or involved in post-incident evaluations. Staff interviews revealed that similar incidents had occurred previously and were sometimes not reported or investigated, and that interventions such as alarm mats were ineffective in preventing recurrence. Facility leadership, including the DON and Administrator, were not consistently notified of all incidents, and investigations were incomplete or delayed. The facility did not report the incidents to the state health department, citing a lack of evidence of injury or mental anguish, despite multiple staff and witness accounts indicating resident distress and inability to consent. The lack of timely assessment, reporting, care plan updates, and comprehensive investigation contributed to the deficiency in protecting residents from abuse and neglect.
Removal Plan
- Facility hall monitors were instated for all three shifts to ensure residents stayed out of other resident rooms
- All residents in the facility were assessed for aggression risk
- Resident #1 was placed on continuous 1:1
- All staff currently working in the facility were educated on abuse, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse
- Staff education was completed online, and multiple department facility staff working were interviewed and were able to demonstrate understanding of the education