Failure to Protect Resident from Abuse
Penalty
Summary
Cheltenham Nursing and Rehabilitation Center was found to be non-compliant with federal and state regulations due to a failure to protect a resident from abuse. Resident R46, who had a history of verbal aggression, physically assaulted Resident R112, resulting in actual harm. The incident involved Resident R46 becoming physically violent, leading to Resident R112 sustaining a closed head injury and a fractured right finger. Resident R46 was assessed as alert, oriented, and independent in activities of daily living, with a history of verbal aggression towards Resident R112. Despite this, the facility did not take adequate measures to prevent further altercations. Resident R112, who had severe cognitive impairment and required supervision for daily activities, was left vulnerable to the aggression of Resident R46. The facility's documentation revealed multiple instances of verbal altercations between the two residents, including a significant incident where Resident R46 threatened Resident R112. The situation escalated to physical violence, witnessed by another resident, resulting in injuries to Resident R112. The facility's failure to address the ongoing aggression and protect Resident R112 from harm was substantiated as abuse.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the facts alleged, or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law. The plan of correction constitutes our credible allegation of compliance. 1. Resident R112 was immediately moved to another unit on October 12, 2024, following the resident-to-resident altercation. Resident R112 and R46 remain on separate units. 2. On 12/26/2024 the nurse management team reviewed the Electronic Health Record (EHR) of residents with a history of verbal or physical aggression towards other residents to identify those that were at high risk. 3. On 12/26/2024 The Social Services Director and Nurse Managers reviewed those residents identified at high risk for verbal and physical aggression. Those identified were referred to psych. The care plans were updated, and medications were reviewed. 4. On 12/26/24 the NHA/designee started education for all staff on the facility's abuse policy and supervision of residents. The education was completed by 12/31/2024. 5. The DON and/or designee will conduct audits of residents at high risk for verbal or physical aggression. Audits will be completed weekly for 4 weeks and monthly for 3 months. Results of the audits will be reviewed at the Quality Assurance Performance Improvement meeting held monthly.