Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse and neglect for four residents reviewed for abuse, resulting in both physical and psychosocial harm. One resident, who was moderately cognitively impaired, was observed in a physical altercation with his roommate, who had a documented history of aggression. The altercation involved striking with closed fists and pushing, yet there was no documentation of the incident in the medical record for two consecutive days. The resident reported feeling scared, unsafe, and unable to protect himself, and had previously informed the Social Services Director about his fear and ongoing issues with his roommate. Despite this, the two residents remained roommates, and the incident was not promptly reported to facility administration or documented by the staff present, including a safety aide who witnessed the event. Another incident involved two severely cognitively impaired residents in a locked dementia care unit. One resident entered another's room, became agitated, and struck the other resident multiple times, resulting in a scratch to the upper lip and reported hits to the face, stomach, and leg. Staff intervened after hearing a commotion, separated the residents, and sent the aggressor for evaluation. Interviews with staff indicated that the aggressor was wandering and appeared confused, believing the other resident was involved with his wife. The care plans for the involved residents did not consistently identify risk for abuse or include appropriate interventions. Across these incidents, there was a lack of timely documentation, reporting, and care planning to address known risks of aggression and abuse. Staff, including RNs and safety aides, were either unaware of the altercations or failed to report them to administration. The facility's failure to implement and document interventions for residents with histories of aggression or cognitive impairment contributed to repeated episodes of resident-to-resident abuse and harm.