Failure to Prevent Staff and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from both verbal and physical abuse, as evidenced by two separate incidents involving staff-to-resident and resident-to-resident abuse. In the first incident, a resident with intact cognitive function and multiple medical diagnoses, including diabetes mellitus and acute kidney failure, reported being verbally abused by an LNA. The LNA entered the resident's room to change oxygen tubing, and when the resident explained the tubing schedule, the LNA called the resident a derogatory expletive, stated the resident was useless due to inability to walk, and instructed the resident not to ring for assistance later. This verbal abuse was corroborated by the resident's roommate and confirmed by the facility's internal investigation and the Director of Nursing. In the second incident, a resident with moderate vascular dementia and anxiety was physically abused by another resident with severe vascular dementia and a documented history of aggressive behaviors. The aggressor struck the other resident multiple times in the face with a closed fist while both were in the day room unsupervised, as LNAs were providing care elsewhere. The aggressive resident's care plan noted prior incidents of physical aggression toward both staff and other residents, with interventions in place to monitor and remove the resident if agitated. Despite these interventions, the lack of supervision allowed the altercation to occur, resulting in physical abuse. The Director of Nursing confirmed the occurrence of this resident-to-resident abuse.