Failure to Prevent Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident physical altercations and staff-to-resident verbal abuse. On the memory care unit, two residents with moderate cognitive impairment and histories of behavioral issues were left unsupervised in a common area. The nurse assigned to the unit, RN K, was in the office with the door closed and did not have visual access to the residents. As a result, a physical altercation occurred in which one resident punched another approximately eight times in the face and head, causing visible injuries including facial swelling and an abrasion. Surveillance video confirmed that the altercation lasted close to two minutes before RN K exited the office and intervened. Staff interviews and documentation revealed that the nurse was slow to respond and did not call for help during the incident. In a separate incident, a resident who was cognitively intact reported being verbally abused by a CNA. The resident stated that after a brief exchange, the CNA used profane language towards him, which made him feel upset and uncomfortable. The incident was corroborated by the resident's roommate and the CNA herself, who admitted to using inappropriate language in response to the resident's provocation. The nurse on duty and the social worker both confirmed that the resident was visibly upset after the incident and that the language used by the CNA constituted verbal abuse. Additionally, another incident involved a resident being physically assaulted by another resident, resulting in the victim being punched in the face. The report details that these failures to provide adequate supervision and to ensure staff refrained from abusive language or behavior led to residents experiencing physical and psychological harm. The facility's lack of timely intervention and failure to maintain a safe environment contributed directly to the deficiencies identified by surveyors.