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 sexual and physical abuse among residents. In one instance, a female resident with severe cognitive impairment and a history of traumatic brain injury was observed with her hand down the pants of a male resident, who was also severely cognitively impaired and diagnosed with schizophrenia and impulse disorder. The male resident held the female resident's hand in place and resisted staff intervention, requiring nursing staff to manually remove her hand. The care plans for both residents did not reflect updates or interventions addressing these sexual behaviors, despite prior incidents of inappropriate sexual conduct by the male resident, including exposing himself and masturbating in common areas, as well as inappropriate physical contact with another female resident who was also severely cognitively impaired and unable to communicate effectively. Additional incidents involved physical and verbal aggression between residents. One resident, with Alzheimer's disease and major depressive disorder, exhibited repeated aggressive behaviors, including hitting another resident on the hand with silverware, throwing coffee, making verbal threats, and physically striking other residents. These behaviors were documented in progress notes, but care plans were not updated to address the ongoing aggression or to provide interventions for the victims. In several cases, staff intervened to separate residents and de-escalate situations, but there was no evidence that these incidents were consistently reported to the abuse coordinator or that care plans were revised to reflect the risks and necessary supervision. The report also details failures in communication and documentation, such as not reporting certain abuse allegations to the state agency in a timely manner and lacking evidence of consent or capacity to consent in cases of alleged consensual sexual contact between cognitively impaired residents. Interviews with staff and family members confirmed awareness of behavioral issues and incidents, but also revealed gaps in monitoring, reporting, and care planning. The cumulative effect of these actions and inactions resulted in an Immediate Jeopardy finding, as the facility did not ensure residents' right to be free from abuse and neglect, and failed to implement adequate supervision, assessment, and care plan updates in response to repeated incidents.