Failure to Protect Resident from Abuse Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse, specifically resident-to-resident physical aggression. On one occasion, a resident with a history of aggressive behaviors physically assaulted another resident, resulting in the victim sustaining a facial injury that required emergency medical evaluation. The aggressor had a documented history of multiple prior incidents of physical aggression toward both peers and staff, as noted in their care plan and facility records. Despite the aggressor's known behavioral risks, the facility did not implement immediate one-on-one safety observations as required by its own policy following the incident. Documentation failed to show that the aggressor was placed on one-on-one supervision immediately after the event, and there were no documented witness statements from residents or staff regarding the incident. Additionally, the care plan for the aggressor was not updated with new interventions after each aggressive episode, contrary to facility policy. The victim was severely cognitively impaired and had no prior documented history of aggressive behaviors. The aggressor was also severely cognitively impaired and had a pattern of physical aggression. The facility's failure to follow its abuse prevention and monitoring policies, including timely implementation of supervision and care plan updates, directly contributed to the occurrence and inadequate response to the abuse incident.