Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations involving a resident with severe cognitive impairment and behavioral issues. One resident, with a history of dementia, anxiety disorder, and repeated falls, exhibited aggressive behaviors that were documented in his care plan. Despite these known behaviors, the resident was able to push another resident, who also had severe cognitive impairment and Parkinson's disease, causing the latter to fall and sustain a fractured coccyx. The incident occurred while the second resident was loudly preaching in the hallway, which agitated the aggressive resident, leading to the physical altercation. Initial assessments did not reveal the fracture, and the injury was only discovered after the resident's family took him to an outside physician, who ordered an x-ray confirming the fracture. Further review revealed additional incidents involving the same aggressive resident. In another event, the resident pushed a different peer to the ground and struck him with a walker. Staff interviews indicated that the aggressive resident's behaviors were unpredictable and often triggered without warning, particularly in the late afternoon or early evening. Staff were unable to determine the root cause of the behaviors, and interventions listed in the care plan included medication management, redirection, and attempts to separate the resident from others. However, these interventions were not sufficient to prevent repeated altercations. Documentation and interviews showed that staff and administration were aware of the resident's escalating aggression but were unable to identify effective interventions or consistently implement measures to protect other residents. The care plans referenced behavioral issues and listed general interventions, but there was a lack of specific, individualized strategies to address the aggressive behaviors. The facility's failure to prevent these incidents resulted in physical harm to at least one resident and placed others at risk of abuse.