Failure to Protect Residents from Abuse and Inadequate Response to Incidents
Penalty
Summary
The facility failed to protect two residents from abuse, including verbal, mental, and physical abuse by staff, as well as resident-to-resident altercations. One resident with anxiety, conduct disorder, depression, and moderate cognitive impairment was subjected to yelling, intimidation, and threats by multiple CNAs during an attempt to assist her with toileting. Staff were observed hollering at the resident, pointing in her face, and insisting she apologize while she was naked and distressed on the bathroom floor. The resident was found crying with fresh scratches on her arm, which staff could not adequately explain. Staff also threatened to withhold snacks as a form of punishment, and failed to report the incident and injuries to the charge nurse in a timely manner. Another resident with dementia and agitation exhibited behaviors that led to two separate resident-to-resident altercations. In one incident, the resident was found holding another resident's arm and struck the other resident in the face with a closed fist. In a separate event, the same resident hit another resident in the mouth during a verbal outburst in the activity room. Both incidents resulted in staff intervention to separate the residents and assess for injuries, though no significant injuries were noted at the time. The facility's policies on abuse, neglect, and exploitation were not followed, as evidenced by staff's failure to prevent and appropriately respond to abusive behaviors, both from staff to resident and resident to resident. Staff did not use appropriate de-escalation techniques, failed to maintain residents' dignity, and did not ensure timely and accurate reporting of abuse or injuries to supervisory staff.