Failure to Prevent Resident-to-Resident Abuse on Dementia Unit
Penalty
Summary
The facility failed to protect residents from verbal, physical, and sexual abuse, particularly on the dementia unit, where 12 separate incidents of resident-to-resident abuse were identified. Multiple residents with severe cognitive impairments and behavioral issues were involved in repeated altercations, including inappropriate sexual contact, physical aggression, and verbal threats. Despite documented histories of aggressive and inappropriate behaviors, the facility did not consistently implement or maintain effective supervision or interventions to prevent further incidents. For example, a resident with a known history of sexually inappropriate behavior and aggression was only placed on increased supervision temporarily after incidents, but this was not sustained, allowing further abuse to occur. Specific incidents included a resident being observed touching another resident inappropriately, repeated physical altercations resulting in injuries such as skin tears and scratches, and verbal abuse and threats. Staff interviews and record reviews revealed that the facility was aware of the risks posed by certain residents but failed to take adequate steps to separate residents or provide continuous supervision as required by their own policies. In several cases, staff reported escalating behaviors and prior warnings, but interventions such as one-to-one monitoring were either not implemented or not maintained, leading to repeated incidents. The facility's documentation and staff statements also showed inconsistencies and a lack of thorough investigation into reported incidents. Some staff statements were unsigned, and there were discrepancies between staff accounts and administrative conclusions. In several cases, administration minimized or dismissed the severity of incidents, citing brief durations or lack of direct observation, despite multiple staff and resident reports to the contrary. The failure to protect residents from abuse and to follow established policies resulted in a finding of immediate jeopardy, affecting all residents on the dementia unit.