Probably speaks to the lack of a continuity of care. If there is not a person who continuously monitors her condition, they'd just assume it had happened on someone elses "watch" so to speak.

maybe they were having their way with her too/ I can't stop thinking about that opening scene in that Kill Bill movie. I can imagine this goes on more than we'd like to think. And I'm guessing she could have been a money maker for some at that facility. Disgusting and sickening.

And who oversees these facilities?

although there are things that disrupt the cycle, such as extreme weight loss, etc., this should be on her daily chart. Every nurse or doctor who read her chart should have caught onto this. Absolutely unacceptable.