Resident-to-Resident Abuse Due to Inadequate Behavior Management
Penalty
Summary
The facility failed to ensure that residents were free from resident-to-resident abuse, as evidenced by an incident involving two residents. Resident R77, who has a history of wandering and taking food that is not his, was involved in an altercation with Resident R37 in the dining room. Resident R77, with a BIMS score indicating moderate cognitive impairment, was eating food from Resident R37's tray when Resident R37 returned and began hitting him with her cane. Resident R37, who is cognitively intact, expressed frustration that Resident R77 frequently attempted to eat her food. The facility's investigation revealed multiple staff members witnessed the incident, including a nurse assistant who saw Resident R37 hitting Resident R77 with her cane. Despite the presence of staff, the facility's documentation was incomplete, as it failed to include a statement from one of the nurse assistants who witnessed the altercation. Additionally, interviews with staff indicated that Resident R77 had a known history of taking food from others, yet there was no documented evidence of interventions or a care plan addressing this behavior prior to the incident. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse and neglect, particularly for those with behavioral or cognitive issues. However, the lack of a care plan for Resident R77's behavior and the incomplete documentation of the incident suggest a failure to adhere to this policy. The facility administrator confirmed the absence of a care plan addressing Resident R77's behavior of taking food from others, highlighting a gap in the facility's approach to managing resident behaviors and preventing abuse.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. R37 and R77 were separated at the time of the incident with no more physical interactions. 2. An initial audit was conducted for past 30 days of resident-to-resident altercations to ensure proper interventions are in place to prevent abuse. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. NHA/Designee will educate all staff on abuse prevention policy and procedures. 4. NHA/Designee will conduct an audit of all resident to resident abuse altercations 3 times per week for 4 weeks then 1 time per month for 2 months to ensure proper interventions/preventions were in place to prevent. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.