Failure to Protect Residents from Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from both resident-to-resident and staff-to-resident physical abuse, as evidenced by multiple incidents involving three residents. One incident involved a resident with Alzheimer's disease and dementia who was struck in the mouth by another resident with a known history of aggression and behavioral disturbances. Documentation and interviews revealed that the aggressive resident had exhibited repeated episodes of anger, verbal and physical aggression, and difficulty with redirection in the weeks leading up to the incident. Despite these documented behaviors, there was no behavior care plan implemented prior to the altercation, and staff supervision was reported as insufficient, particularly when staffing levels were low or when unfamiliar staff were present on the unit. Another incident involved a cognitively intact resident who reported being struck in the face by an agency LPN during an argument about the administration of an insulin injection. Multiple interviews with staff and witnesses confirmed that a physical altercation occurred, with the resident sustaining a bloody lip and both parties engaging in yelling and physical contact. The LPN admitted to pushing the resident's hands away after being poked in the chest, and a police report classified the event as a simple assault. The facility's investigation into this incident was incomplete, as only one written witness statement was collected and not all available witnesses were interviewed. The facility's abuse prevention policy requires ongoing assessment, care planning, and monitoring of residents with behavioral issues, as well as immediate reporting and investigation of abuse allegations. However, the facility did not implement appropriate interventions or supervision for residents with known aggressive behaviors, nor did it conduct a thorough investigation into the staff-to-resident abuse incident. These failures resulted in residents being exposed to physical harm and not being protected from abuse as required by facility policy and regulatory standards.