Widespread Abuse, Neglect, and Inadequate Supervision Identified
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and inadequate care, as evidenced by several documented incidents. One incident involved a nurse physically abusing a resident with Huntington's disease and severe cognitive impairment by lifting her from a wheelchair and throwing her onto a mattress on the floor, resulting in visible bruising and redness. Another incident involved a nurse verbally abusing a resident by yelling, cursing, and refusing pain medication, as corroborated by the resident, her family member, and other staff who witnessed the nurse's erratic and inappropriate behavior. Additionally, the facility did not prevent resident-to-resident physical abuse, as one resident with dementia and behavioral issues shoved another resident on two occasions, resulting in scratches and a fall. The care plans for these residents did not adequately address behavioral risks, and supervision was insufficient to prevent these altercations. The facility also failed to ensure proper positioning during tube feeding for a resident with severe cognitive and physical impairments, leading to aspiration pneumonia and hospitalization. Video evidence showed the resident left in an unsafe position for an extended period, with minimal staff intervention. Further deficiencies included inadequate staffing to provide necessary wound care, feeding assistance, and supervision during meals and on the secured unit. Multiple residents did not receive timely or appropriate care for pressure ulcers, feeding, and fall prevention. Staff interviews revealed ongoing concerns about insufficient staffing, lack of support from management, and inadequate training, which contributed to the inability to meet residents' needs and prevent harm.