Failure to Implement Abuse Policies and Investigate Multiple Abuse Allegations
Penalty
Summary
Facility administration failed to implement its abuse policies and procedures for 15 of 25 sampled residents, resulting in noncompliance that surveyors determined had caused or had the likelihood to cause serious injury, harm, impairment, or death. The Administrator did not ensure residents remained free from neglect and abuse after multiple allegations of physical, sexual, and other forms of abuse were made by and between residents and staff. Specific incidents included a resident alleging that a staff member grabbed him by the shirt and threw him against a doorframe, causing a laceration above his eye, and several residents reporting that other residents touched them inappropriately in their private areas or engaged in sexual abuse. Another incident involved a resident slapping another resident in the face without provocation. In each of these situations, the administration failed to ensure adequate actions were taken to prevent further potential abuse by staff or residents. The Administrator also failed to ensure thorough investigations of abuse allegations for 14 residents reviewed for abuse. Despite multiple reports and observations of alleged abuse, including sexual abuse between residents, physical abuse by staff toward a resident, and physical abuse between residents, the facility did not conduct comprehensive investigations as required. During an interview, the Administrator and DON confirmed that the facility lacked policies and procedures directing staff on how to identify, report, investigate, and prevent resident abuse, despite the Administrator’s job description assigning responsibility for assuring that care promotes quality, safety, and respect. Surveyors identified Immediate Jeopardy beginning when one resident alleged that another resident sexually abused her by touching her between her legs, and found that the facility’s failure to implement its Abuse Policy placed all residents at risk of unreported and uninvestigated abuse.
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