Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse perpetrated by another resident. Resident 366, who was cognitively intact, reported that Resident 180 entered her room and physically assaulted her by poking and punching her thigh, causing pain. Despite the facility's policy against abuse, Resident 180, who had a history of aggressive behavior and severe cognitive impairment, was not adequately monitored or redirected, leading to this incident. Resident 180, diagnosed with severe vascular dementia and metabolic encephalopathy, exhibited a pattern of aggressive and intrusive behaviors, including wandering into other residents' rooms and physical aggression towards staff and residents. The facility's documentation indicated that Resident 180's behaviors were known, yet proactive measures to prevent incidents were insufficient. On another occasion, Resident 180 approached Resident 52 in the hallway and slapped him on the cheek, despite the resident being seated and not posing any threat. The facility's failure to implement sufficient supervision and monitoring measures for Resident 180, given his known history of aggression, resulted in physical abuse of Residents 366 and 52. The incidents highlight a lack of effective intervention strategies to manage Resident 180's behaviors, leading to harm and distress for other residents.
Plan Of Correction
Step 1 - No ill side effects noted with R52. R366 was discharged with no ill effects. R180's POC was reviewed and an updated activity assessment was completed to assess possible diversional activity interests. Step 2 - To identify other residents that have the potential to be affected, residents that exhibit aggressive behaviors will be reviewed by the IDT. Care plans will be updated, as necessary. Step 3 - To prevent this from reoccurring, re-education of the abuse policy and behavior interventions will be completed with facility staff by the staff educator/designee. Step 4 - To monitor and maintain compliance, the DON/designee will review 10 residents that exhibit aggressive behaviors to ensure that behaviors are addressed and care plan interventions are appropriate for behaviors exhibited. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.