Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Care Planning and Monitoring
Penalty
Summary
The facility failed to establish an environment that promotes resident sensitivity, safety, and prevention of mistreatment, resulting in an incident of abuse between two residents. One resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment was placed in a room with another resident who had a history of severe cognitive impairment, schizoaffective disorder, bipolar type, anxiety disorder, and repeated aggressive behaviors toward staff and other residents. Despite multiple documented incidents of aggression and behavioral concerns for the second resident, including physical aggression, verbal outbursts, and the need for antipsychotic medication, there was no documented care plan or intervention specifically addressing abuse prevention for the first resident after the room transfer. The care plan for the aggressive resident indicated a need for separation from others as needed due to behavioral symptoms, but this intervention was not implemented when the two residents were placed together. Staff interviews revealed a lack of awareness regarding the rationale for the room assignment and an absence of specific interventions to prevent abuse following the transfer. The aggressive resident's care plan also called for ongoing assessment for aggression, but there was a gap in aggression assessments between the date of the care plan intervention and the actual abuse incident. On the day of the incident, the resident with moderate cognitive impairment was physically assaulted by the aggressive resident, resulting in injuries to his ribs and head. Staff responded after hearing commotion, but the incident occurred quickly and without prior intervention. The room where the incident occurred was not located near the nurse station, contrary to staff belief that it was, and there was no evidence that enhanced monitoring or other preventive measures were in place at the time of the incident.