Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions and Staff Education
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse after a resident with severe cognitive impairment and a history of agitation and aggression was not provided with appropriate interventions or increased supervision. Despite documented behaviors such as wandering, suspicion, agitation, and combativeness, there was no behavior care plan for aggression in place for this resident until after multiple incidents occurred. Staff were not educated on increasing supervision or on specific interventions following an initial altercation where the resident threw a handheld radio, striking another resident. Subsequently, the same resident was involved in a second incident where he physically shoved a trash can into another resident's face, resulting in a bleeding laceration to the upper and lower lips. Staff interviews revealed that there were no individualized interventions for residents on the dementia unit, and that staff had not been educated on communication, redirection strategies, or monitoring for signs of agitation after the altercation. Additionally, the two residents involved in the altercation continued to have rooms next to each other, despite ongoing conflict and aggressive behaviors. The facility's own policies required the identification, assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, as well as staff training and ongoing supervision. However, these policies were not implemented as written, and there were system failures regarding care plans, documentation, and communication of interventions to floor staff. The lack of timely and effective interventions resulted in physical harm to a resident and placed all residents in the dementia unit at risk.
Removal Plan
- The DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment.
- 15-minute checks for R1 changed to 1:1 supervision.
- R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications.
- R1's care plan updated with individualized interventions for aggressive behaviors.
- R1 is not to be seated by other residents with activities, dining etc. when agitated.
- Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention.
- All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift.
- R1's abuse and aggression assessments completed/updated.
- R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1.
- Abuse policies reviewed/revised to include resident to resident altercations.
- Abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff.
- DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee.
- An emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.