Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. On one occasion, a resident with a history of aggression due to dementia struck another resident in the face with a walker, causing lacerations and bruising. The aggressive resident had a known history of physical and verbal aggression and was supposed to have a stop sign across their door to prevent others from entering, but it was unclear if this was in place at the time of the incident. The injured resident, who was cognitively impaired and had a hearing deficit, was in pain and required medication following the incident. In another series of incidents, two residents who were roommates engaged in physical altercations on multiple occasions. Both residents had cognitive impairments and histories of aggressive behavior. Despite being placed on 15-minute checks after the first altercation, they remained roommates and continued to have conflicts, including slapping each other and being found crawling on the floor after a struggle. The facility was aware of the incompatibility between the two residents but did not have alternative accommodations available on the secure unit. The facility's policies on abuse prevention and reporting were not effectively implemented, as evidenced by the repeated incidents of resident-to-resident abuse. Staff interviews revealed that there were concerns about the aggressive behaviors of certain residents, but these concerns were not adequately addressed to prevent harm. The facility's failure to ensure proper supervision and intervention contributed to the incidents, and there was a lack of documentation regarding preventive measures such as the placement of stop signs.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. As per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. - A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there are no ongoing negative psychosocial impact. - Additional signage will be placed on the resident’s door to deter others from wandering into the resident’s room. - Certified Nursing Aide #1, Social Worker #1, Registered Nurse Head Nurse #2 and Licensed Practical Nurse #1 will receive educational counseling on their role to identify potential for abuse and prevent abuse from occurring including ensuring that preventative measures such as stop signs were in place per plan of care. - Resident #17: - An assessment by a Registered nurse was completed on each altercation between resident #17 and #75. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact due to the altercations and the subsequent room changes. - Resident #75: - An assessment by a registered nurse was completed upon each altercation with resident #17. No injuries were identified. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. - Resident #75 was moved to a private room on a different unit. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations. - Licensed Practical Nurse #1 and Certified Nursing Aide #1 will be educated on their role to report resident issues including resident to resident verbal altercations immediately. - Registered Nurse #1 will be educated on their role to put interventions into place to prevent/reduce risk of abuse and prevention of recurrence. - The Director of Nursing and Assistant Director of Nursing were educated on their role to investigate reports of verbal altercations between residents as potential incidents of abuse and institute measures to prevent recurrence. II. As per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed to identify any incidents of actual or potential abuse, neglect or mistreatment. - The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. As per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect – Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - The facility Comprehensive care planning policy was reviewed and updated by the consultant with administration and nursing leadership to include the requirement to revise the care plan with interventions to prevent recurrence of incidents including abuse. - As per the Directed Plan of Correction, the Consultant has developed and will implement an In-service Program to address: - Abuse Identification, Prevention and Reporting: - All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: - The Administrator, Director of Nursing and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved. - Regulatory Changes: - All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. - Care Planning: - All nursing leadership and social work staff will be educated by the consultant on the care plan policy updates specific to identifying Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, initiating interventions to prevent or reduce the risk of abuse and revising care plan with interventions to prevent recurrence of abuse. - The facility will monitor for increase resident-resident altercations and or injuries of unknown origin that may signal or alert staff that a problem is potentially evolving. - All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: - As per the Directed Plan of Correction, a Quality Assurance Committee meeting was held on (MONTH) 24, 2024, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plan updated accordingly. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assurance Committee monthly for three months. The consultant will participate in Quality Assurance for three months. Frequency of ongoing audits will be determined by the Committee based on audit results. - Consultant will participate in the Quality Assurance Committee Meeting monthly x 3 months. The administrator will be responsible to ensure corrective action is implemented.