Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from abuse, including verbal and physical abuse, as evidenced by multiple resident-to-resident altercations. In one incident, two residents engaged in a verbal and physical altercation in the supervised smoking area, where one resident pushed another, resulting in a fall, and attempted to slap him. The care plans for these residents did not reflect timely or adequate interventions to address their behavioral risks, and documentation of the incident was incomplete in the medical records. Additionally, the behavior care plan for one of the residents was not initiated until after a subsequent incident occurred. Another event involved a resident slapping another during an argument in the dining room, causing the victim to lose balance and fall, resulting in redness to the eye. The facility substantiated this as physical abuse, but the care plan for the victim was not updated with new personalized interventions to prevent further abuse. Furthermore, behavior monitoring records did not accurately reflect the occurrence of the incident, and there was a lack of interdisciplinary team documentation and follow-up in the medical record. A third incident occurred during a supervised smoking session, where a resident became agitated, overturned a smoking cart, verbally abused another resident, and then struck her on the hand. The care plan for the victim did not include new interventions after the altercation, and there was no nursing progress note documenting the incident or the RN assessment. Staff interviews revealed a lack of awareness of special interventions for residents with known behavioral issues, and supervision in the smoking area was inconsistent with facility policy. The facility's process for documenting and care planning after such incidents was found to be lacking, with no formal interdisciplinary documentation and incomplete updates to care plans.