Failure to Secure Rehabilitation Equipment Leads to Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when a resident obtained a rehabilitation dowel without authorization and used it to physically assault two other residents. The dowel, a piece of equipment intended for therapy, was stored unsecured in the rehabilitation room, which was not consistently locked or supervised outside of therapy hours. Staff interviews and observations confirmed that dowels and other equipment were accessible on the wall, and the rehabilitation room door was only locked when staff left the facility for the day, not during all unsupervised periods. One resident, with a history of anxiety disorder and cognitive decline following a stroke but assessed as having intact cognition, accessed the unsecured dowel and used it to strike another resident on the left arm and, in a separate incident, to hit a different resident on the right arm, right shoulder, and face before pushing her to the floor. The assaulted resident, who had hemiplegia and hemiparesis following a stroke and used a walker for mobility, sustained a non-displaced fracture of the mid sacrum and required transfer to an acute care hospital for evaluation and pain management. Multiple staff and resident interviews corroborated the sequence of events, including the use of the dowel as a weapon and the lack of immediate staff intervention to prevent the assault. The facility did not follow its own policy and procedure regarding the prevention, reporting, and correction of abuse, neglect, and mistreatment. The investigation revealed that staff failed to secure the rehabilitation room and its equipment, did not prevent the resident from accessing the dowel, and did not implement interventions to address the resident's behavioral risks or prevent further incidents. The lack of supervision and security measures directly contributed to the occurrence of physical abuse and injury among residents.