Failure to Protect Residents from Abuse, Neglect, and Deprivation of Services
Penalty
Summary
Multiple residents experienced abuse, neglect, and deprivation of services due to staff actions and inactions. Several residents were left in urine-soaked briefs and bedding overnight, and some were not assisted with toileting or repositioning as required. One resident, who required a Hoyer lift for transfers, was not consistently checked or changed, resulting in three new areas of moisture-associated skin damage, including incontinence-associated dermatitis on both thighs and the intergluteal cleft. Another resident was left unclothed and soiled in bed after a CNA complained about having to change her, and was not assisted out of bed as needed. Residents reported being afraid to use their call lights due to staff behavior, and grievances were filed regarding rough and verbally abusive treatment by staff. Staff failed to provide care in accordance with professional standards, as evidenced by multiple grievances and facility-reported incidents. One resident was left on the commode for an extended period and had to return to bed without assistance. Another resident was not properly turned and repositioned, resulting in being found wet with urine and requiring a full bed linen change. There were also reports of staff yelling at residents, refusing to provide assistance, and being rough or mean during care. In one case, a resident who fell while attempting to brush his teeth was verbally abused by staff, who then removed his call light, water, and bedside table, leaving him unable to call for help. The facility received numerous grievances from residents and families regarding inadequate care, verbal abuse, and neglect. Staff interviews and documentation confirmed that several staff members, including agency and travel staff, were implicated in these incidents. In some cases, the abuse was not properly investigated or reported to the State Survey Agency. The Director of Nursing and other staff were made aware of these issues through incident reports, grievances, and direct observation, but the deficiencies persisted, affecting at least ten residents.