Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in several resident-to-resident altercations involving four out of six sampled residents. Incidents included one resident being pushed and slapped by another, a resident being pushed to the floor after a dispute over a shoe, and repeated altercations between two residents who both exhibited cognitive impairments and behavioral disturbances. In each case, the residents involved were either unable to recall the incidents due to cognitive deficits or were non-verbal, and staff or other residents witnessed the altercations. The care plans for the residents involved did not consistently identify them as being at risk for abuse or as having been victims of physical abuse, even after multiple incidents had occurred. Updates to care plans and the implementation of new interventions were delayed, with some changes not made until after several additional altercations had taken place. For example, one resident's care plan was not updated to reflect her risk for abuse or to include new interventions until after she had been involved in three more altercations following the initial incident. Despite the facility's policy stating a commitment to preventing abuse and providing a safe environment, the measures in place, such as 15-minute checks and staff education, did not prevent further incidents. The documentation also revealed that some injuries, such as bruising, were not clearly accounted for in the medical record, and the interventions implemented did not effectively reduce the frequency of resident-to-resident abuse. The facility's failure to promptly and adequately address the risk factors and behavioral triggers for these residents contributed to ongoing physical altercations and a lack of protection from abuse.