Failure to Investigate and Prevent Resident-to-Resident Abuse and Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of verbal and sexual abuse, did not implement interventions to prevent further abuse during ongoing investigations, and did not take appropriate corrective actions to ensure that abuse or mistreatment would not recur. Several residents were involved in incidents where one resident repeatedly entered female residents' rooms without permission, including while they were sleeping. Staff redirected the resident and notified supervisors, but the behavior continued over several days. Documentation shows that social services and nursing staff were aware of the ongoing incidents, but interventions were limited to redirection and verbal warnings, with no evidence of more robust measures to prevent recurrence during the investigation period. In one case, a resident with Huntington's Disease, mood and anxiety disorders, depression, and legal blindness reported that another resident attempted to be sexual with her by touching her arms and legs. She called 911 and was taken to the hospital, but assessments found no physical evidence of abuse. The resident's mother, who is her MPOA, confirmed her daughter's paranoia and blindness and was aware of the incident. The facility submitted an initial report to the state agency and conducted interviews, but the investigation was deemed inconclusive, and there was no documentation of further protective interventions for the resident or others potentially at risk. Other residents were also involved in incidents where the same resident attempted to enter their rooms or engaged in inappropriate verbal exchanges. In several cases, there was no documentation that the facility interviewed the potentially affected residents to ensure their safety or freedom from abuse. Additionally, an incident involving verbal abuse between residents was logged as a grievance but not recognized or reported as abuse, and no investigation or action was taken to prevent recurrence. The facility's response to these incidents lacked thorough investigation, timely interventions, and appropriate follow-up to protect residents from further abuse or mistreatment.