Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from verbal and emotional abuse and/or neglect, as evidenced by incidents involving three residents. One resident with dementia and a history of stroke, who was cognitively intact but frequently incontinent, was found by staff to be in a heavily soiled brief and bed linen, with visible redness and a scabbed area on the toe. Documentation showed a significant gap in incontinence care, with the resident stating he had not been changed for an extended period and reporting that this neglect was a recurring issue. Staff statements corroborated the resident's account, describing the resident's condition as deplorable and noting that concerns had been reported multiple times without resolution. Another resident with dementia and a history of stroke, who was always incontinent and had moderate cognitive impairment, was also not provided with incontinence care on multiple occasions. Therapy staff reported finding the resident in extremely soiled briefs and bedding, with a strong odor and visible soiling, and documented that these findings were brought to the attention of supervisory staff. Care records indicated several days without documented incontinence care, further supporting the neglect. A third resident with diabetes and heart failure, who had moderate cognitive impairment, was subjected to verbal abuse by a nurse aide. The resident reported being called an offensive name by the staff member while in a public area of the facility, and this was confirmed by statements from other employees. The incident was witnessed by two staff members, and the resident expressed feeling surprised and offended by the verbal abuse.