Failure to Prevent Resident-to-Resident Altercations and Neglect of Timely Care
Penalty
Summary
The facility failed to prevent resident-to-resident altercations and did not ensure residents were free from neglect, as evidenced by multiple incidents involving several residents. In one instance, a resident with dementia and severe cognitive impairment was punched in the face by another resident with Alzheimer's disease and a history of agitation and aggression. The altercation occurred in the dining room and was witnessed by a visitor. Documentation revealed that the care plan for the aggressive resident included interventions such as keeping the resident near the nursing station and providing one-on-one supervision, but these measures were not effectively implemented at the time of the incident. The event was not documented in a timely manner, and the initial nursing note failed to identify the actual date of the altercation. Another incident involved a resident with Alzheimer's disease and behavioral disturbances who became agitated during morning care and pushed a nurse aide, then pushed another resident, causing that resident to fall. The care plan for the aggressive resident included interventions to approach the resident calmly and anticipate needs, but the resident had recently become more impulsive and difficult to redirect. Staff interviews confirmed that the resident was agitated and that the incident occurred while another resident was walking by. Additionally, the facility failed to provide timely incontinent care to four residents with varying degrees of cognitive impairment and physical dependency. Documentation and staff interviews revealed that these residents went extended periods—ranging from nearly 7 to over 10 hours—without receiving incontinent care, despite care plans directing checks every two hours. The nurse aide responsible for their care did not check on the residents as required and did not notify supervisory staff when assistance was needed. The facility's investigation substantiated that neglect had occurred, as the residents did not receive necessary care to avoid physical harm or distress.