Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that Resident 40 was free from physical abuse by another resident, Resident 81. Resident 40, who was moderately impaired cognitively with a BIMS score of 9, was admitted with diagnoses including unspecified dementia and generalized anxiety disorder. Resident 81, who was severely impaired cognitively with a BIMS score of 4, had a history of aggressive behaviors, including agitation, verbal and physical abuse towards staff and other residents, and refusal of medications. Despite these behaviors, the facility's care plan for Resident 81 did not identify specific behaviors or implement person-centered interventions to manage the resident's aggression. On January 23, 2025, Resident 81 was involved in an altercation with Resident 40, during which Resident 81 struck Resident 40 in the chest while she was sitting in her wheelchair. A facility investigation confirmed the incident, and a staff member witnessed Resident 81 hitting Resident 40 and grabbing her by the shirt. The facility's failure to develop and implement appropriate interventions for Resident 81's known aggressive behaviors resulted in the physical abuse of Resident 40.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared solely because it is by the provisions of federal and state law. The plan of correction represents the facility's credible allegation of compliance as of March 25, 2025. 0600 Resident 81's care plan has been reviewed and updated to reflect approaches to managing her socially inappropriate behavior. Residents with documented behaviors will have care plans reviewed and updated by The Clinical Care Coordinator to ensure appropriate approaches/interventions have been developed, documented, and implemented to attempt to manage the behavior noted and to protect others. The Regional Social Service Director will provide re-education to the Clinical Care Coordinator, Social Service Director, and Licensed nursing staff on how to develop and implement a socially inappropriate behavior care plan to ensure the safety of residents. Behaviors will be reviewed at daily morning IDT meetings and care plans reviewed to verify they address appropriate interventions. The Clinical Care Coordinator or designee will perform random audits weekly for 4 weeks and then monthly for 2 months identifying resident behavior and ensuring the developed care plan is in place. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.