Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide an environment free from abuse for three residents, resulting in multiple incidents of resident-to-resident physical and verbal abuse. One resident with a history of severe cognitive impairment and behavioral symptoms, including physical and verbal aggression, was involved in several altercations with other residents. Documentation and staff interviews confirmed that this resident exhibited aggressive behaviors such as yelling, pushing, slapping, and making threats toward other residents over a period of several weeks. These behaviors were observed in various settings, including the hallway, dining room, and shared bathrooms, and were witnessed by staff and other residents. Specific incidents included the resident pushing another resident in the chest after being provoked, grabbing and attempting to pull a resident off the toilet, slapping another resident across the face, and swatting a resident in the head in the dining room. Progress notes and staff interviews indicated that the resident's aggressive behaviors were ongoing and that other residents expressed fear and distress as a result. The aggressive resident was noted to be ambulatory and able to move quickly, which contributed to the difficulty in preventing these incidents. Staff reported that the resident's behaviors were well-known and that many residents would avoid common areas or seek proximity to the nurses' station when the resident was present. Despite the resident's documented history of aggression and the facility's policy prohibiting abuse, the facility did not effectively prevent repeated episodes of physical and verbal abuse between residents. The ongoing nature of the behaviors, the frequency of altercations, and the impact on other residents' sense of safety and well-being were substantiated through interviews, progress notes, and incident reports. The facility's failure to prevent these incidents resulted in a deficiency related to the requirement to maintain an environment free from abuse, neglect, and exploitation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed in accordance with federal and state law requirements. Element 1: Resident R1 is currently safe in facility. A psych tele-visit was completed on 4-28-25 and recommendations being reviewed. A medication review was requested on 5-2-25. Facility met with guardian on 4-25-25 related to R1 decline. Guardian declined change in Advanced Directive and hospice services at this time. R1 was sent to ED on 4-30-25 after presenting with a significant decline related to dementia diagnosis. Facility will continue to monitor R1 through documented target behaviors, 24 hour report, and staff reporting. R1 has had no reportable incidents with other residents since 2-10-25. Resident R2 is currently safe in facility. A chart review was completed and plan of care is current as written. Resident R6 is no longer in facility. Element 2: All residents have the potential to be affected. Facility has completed a 7 day look back on resident skin assessments with a BIMS of 8 or below. Residents with a BIMS of 9 or above have been interviewed to ensure they feel safe in facility and have no concerns related to other residents. IDT reviewed interviews and no concerns related to other residents were identified. Facility identified residents with behaviors affecting others and care plans and interventions have been reviewed and are current as written. Element 3: Re-education will be completed by 5-8-25 or before next shift worked with all staff related to the Abuse and Neglect Policy and behaviors affecting others. Administrator and Director of Nursing have reviewed the Abuse and Neglect Policy and deemed it appropriate. Element 4: Random audits of 5 interviewable residents and 5 non-interviewable residents will be completed weekly for 4 weeks. 10 staff members weekly for 4 weeks will be quizzed on how to manage behaviors and offer support to residents. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator and Director of Nursing are responsible for achieving and sustaining compliance.