Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents' rights to be free from physical abuse. One resident with severe dementia and a history of wandering entered another resident's room and mistakenly got into his bed. The second resident, also severely cognitively impaired, was observed by staff with his hands on the first resident's shoulders and then making contact with an open hand to the side of her face. Witness statements from staff and a housekeeper confirmed that the second resident pinned the first resident to the bed and slapped her on both sides of her face before staff intervened. The first resident was upset but did not sustain visible injuries. Prior to this incident, the first resident had a documented history of wandering into other residents' rooms and had previously been involved in another physical altercation after entering a different resident's room. Interventions such as 15-minute checks and a companion during evening hours had been implemented due to her increased confusion and wandering behaviors. Despite these measures, the resident was able to enter another resident's room unsupervised, leading to the physical abuse incident. Both residents involved were severely cognitively impaired, with documented diagnoses of dementia and other neurological conditions. The first resident's care plan noted altered mobility, poor safety awareness, and a need for redirection due to wandering. The second resident had no recall of the incident and was also noted to be confused. The failure to adequately supervise and prevent the first resident from entering other residents' rooms resulted in a situation where she was physically abused by another resident.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #58 and Resident #60 will have a review of the person-centered plan of care review to mitigate further resident to resident interactions. ELEMENT #2: Identification of Other residents: Lake Woods strives to establish clinical and psychological support practices for our residents that limit the opportunity for avoidable interactions. Residents residing in the facility that are identified as having wandering behavior will be identified through a review of MDS section E0900 and will have a review to their person-centered plan of care interventions to mitigate risk of avoidable resident to resident occurrences. Root cause analysis will be completed, and any opportunities that are identified will be care planned. ELEMENT #3: Systemic Changes: Lake Woods will consistently follow Policies and Procedures Protecting our residents from abuse and mistreatment. All staff will be reeducated by 5/26/2025 or prior to their next day worked in the event of a leave of absence or vacationing employee, regarding the abuse and neglect protocols. Specific examples of possible interventions will be included in the education that may reduce the risk of other resident to resident interactions from occurring. The reeducation will include an Abuse prevention overview including a review of policies entitled; Abuse Suspected Abuse Investigations; Abuse Prevention Overview; and Resident to Resident Interactions. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will review the implementation of interventions to mitigate the risk of an avoidable event 3-5 times a week for four weeks enquiring with staff to evaluate understanding and implementation of interventions to prevent high risk events. The Director of Health Care Services or designee will provide a report to QAPI for one (1) month. The Administrator assumes responsibility for attained and sustained compliance.