Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, despite multiple documented incidents of aggressive behavior. One resident with severe cognitive impairment and a history of both physical and verbal aggression, including wandering, was involved in several altercations targeting another resident. These incidents included attempts to kick, ramming with a wheelchair, verbal insults, and physical attacks such as kicking in the face and legs. Staff progress notes documented a pattern of escalating behaviors over several months, with specific references to the aggressor seeking out and targeting the same resident multiple times. Despite these ongoing incidents, the resident's care plan did not include interventions to address or prevent abusive behaviors toward others until after a significant incident occurred. Staff interviews confirmed awareness of the aggressor's pattern of seeking out and attempting to harm the other resident, yet no specific measures were implemented to prevent further abuse prior to the addition of interventions on the care plan. The facility's own abuse prevention policy defines resident-to-resident physical contact resulting in harm, pain, or mental anguish as abuse, and presumes such outcomes in residents with cognitive or physical impairments, even if no immediate injury is observed. The resident who was targeted had severe cognitive impairment, Alzheimer's disease, Down Syndrome, moderate intellectual disabilities, and was on hospice care. There were no behaviors noted for this resident during the assessment period. Staff and administrative interviews revealed a lack of timely reporting and investigation of the incidents, as well as a failure to notify family and the physician. The deficiency centers on the facility's inaction in updating the care plan and implementing protective interventions despite clear evidence of ongoing abuse.