Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision and Staffing
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically in the male secure unit, due to insufficient staffing and inadequate supervision. Multiple incidents of resident-to-resident abuse occurred, including physical altercations and sexual abuse. In one case, a resident with severe cognitive impairment was pushed by another resident, resulting in a fractured toe and other injuries. Other incidents included residents being hit or slapped by peers, with some residents having documented histories of behavioral disturbances and aggression. Staff interviews and records revealed that these behaviors were known, yet interventions and monitoring were not consistently implemented or effective in preventing further incidents. The report details that only one CNA was often assigned to the male secure unit, which was insufficient to monitor and manage the residents' behaviors. Staff reported that aggressive and inappropriate behaviors had been communicated to nursing leadership, but no additional support or changes were made. In several cases, residents with known behavioral issues were not provided with adequate supervision or behavioral interventions prior to the incidents. Documentation shows that staff were aware of escalating behaviors, such as verbal threats and physical aggression, but responses were delayed or limited to after-the-fact monitoring and separation of residents. A particularly severe incident involved a resident sexually assaulting his roommate, who was cognitively impaired and unable to recall the event. The assault was discovered during a routine room check, and the victim was subsequently sent to the hospital for evaluation. Prior to this, the perpetrator had a documented history of sexually inappropriate comments and behaviors, but interventions were limited to staff training and general supervision. The lack of effective preventive measures and insufficient staffing contributed directly to the occurrence of these abusive events.