Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment, including dementia and a BIMS score of 4, who was found engaging in sexual activity with a male resident, also diagnosed with dementia and other neurological conditions. Staff discovered both residents naked from the waist down and engaged in sexual activity. Prior to this, the same two residents were found lying in bed together, fully clothed, with the male resident's hand on the female resident's leg. In both cases, staff failed to recognize or report the incidents as abuse or neglect, despite being trained to do so, and did not immediately notify the administrator as required by facility policy. Another incident involved a nonverbal female resident with severe cognitive impairment and a history of aggressive behaviors. A CNA was observed by therapy staff forcefully grabbing and shaking the resident's wrist after the resident attempted to slap the CNA. The physical therapist intervened, and the resident became emotional and refused therapy, not returning to her baseline until the following day. The CNA denied shaking the resident's arm but was terminated following an investigation that confirmed physical abuse. Interviews with staff revealed a lack of understanding and inconsistent application of abuse and neglect reporting protocols. Several staff members, including CNAs and LVNs, admitted to not reporting incidents as abuse or neglect because they did not perceive the actions as malicious or because the residents involved were confused. The administrator was not notified of the incidents in a timely manner, and the facility's policies regarding immediate reporting and protection from abuse were not followed.