Failure to Prevent Resident-to-Resident Abuse and Neglect During Transfer
Penalty
Summary
The facility failed to protect several residents from abuse and neglect, as evidenced by multiple incidents involving both resident-to-resident abuse and staff neglect. Four residents experienced physical abuse from other residents, despite the facility being aware of the aggressors' behavioral risks and having care plans in place. Specifically, one resident with severe cognitive impairment and a history of aggression physically assaulted three other residents on separate occasions, including slapping, punching, and pushing, even while under one-to-one supervision. Another resident, who was cognitively intact but had a documented low tolerance for confused residents, repeatedly struck a severely cognitively impaired resident with a door, resulting in pain and injury. In both cases, the facility failed to implement effective interventions or adequate supervision to prevent these altercations, despite being aware of the risks and having care plans that addressed these behaviors. Additionally, the facility failed to prevent neglect in the case of a resident with end-stage renal disease and bilateral below-the-knee amputations, who required two-person assistance and a mechanical lift for all transfers as per physician orders and care plan. An agency nurse aide transferred this resident without the required lift or second staff member, resulting in the resident falling to the floor and sustaining a rib contusion and significant pain. The aide had received training and was documented as competent in transfer techniques, yet did not follow the established protocols. The incident was further compounded by the presence of clutter and spilled water on the floor, which contributed to the fall. Interviews with staff and the Nursing Home Administrator confirmed the facility's responsibility to prevent abuse and neglect, and acknowledged that the required interventions and supervision were not effectively implemented. Documentation also revealed gaps in the facility's investigation, such as the lack of a resident interview following the fall. The facility's failure to adhere to its own policies and care plans resulted in residents experiencing physical harm and emotional distress.