Failure to Protect Resident from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of domestic abuse from physical abuse by another resident. The resident, who had a BIMS score of 1 indicating severe cognitive impairment and a care plan noting a history of an abusive spousal relationship, was involved in two separate incidents where another resident allegedly hit her. The first incident was reported by a roommate who overheard the altercation and by the resident herself, who stated she was hit on the chin and stomach. The second incident was witnessed by another resident and resulted in visible injury, with the resident crying and calling the police after being struck on the face. Following the first incident, the interdisciplinary team met to discuss the situation, but the care plan created for the victimized resident was incomplete, lacking specific goals and interventions to prevent further abuse. Additionally, the staff member responsible for social services was unaware of the resident's history of abuse until after the first altercation, and the care plan had not been updated to reflect this risk. Documentation and monitoring of the alleged perpetrator were also lacking, as confirmed by the ADON, who noted that there was no evidence of increased supervision or monitoring after the initial incident. Facility policies required staff to identify and respond to potential abuse, including providing adequate supervision when resident-to-resident altercations are suspected and updating care plans accordingly. However, these procedures were not followed, as evidenced by the lack of documented interventions, incomplete care planning, and insufficient monitoring of both the victim and the alleged perpetrator. This failure resulted in repeated abuse and emotional distress for the resident involved.