Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both staff-to-resident and resident-to-resident abuse. In one instance, a female resident with a history of cerebral infarction, schizophrenia, and hemiplegia was subjected to unwanted sexual contact by another resident, who entered her room and rubbed her leg under the covers without consent. The incident was witnessed by a hospice RN, and the resident expressed that she was upset by the event. The perpetrator had a documented history of inappropriate sexual behaviors and was cognitively intact at the time of the incident. There were also multiple cases of physical and verbal abuse perpetrated by staff members against a male resident with traumatic brain injury, dementia, and severe cognitive impairment. One CNA was observed by another staff member to have called the resident derogatory names, physically restrained him during care, and used excessive force, including pinning him against a wall and stomping on his feet. Another CNA was reported to have verbally abused the same resident and forcefully pushed him into a chair. Both incidents were substantiated by witness statements and resulted in the termination of the staff involved. Additionally, the facility failed to prevent and appropriately manage numerous resident-to-resident altercations, resulting in physical harm such as scratches, hitting, and other aggressive behaviors. These incidents involved residents with significant cognitive and behavioral impairments, including dementia, bipolar disorder, and psychotic disorders. The care plans for these residents indicated known risks for aggression and behavioral issues, yet the facility did not effectively intervene to prevent repeated episodes of abuse among residents.