Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, protect, assess, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with severe cognitive impairment and a history of aggressive behaviors. Staff documented multiple incidents where this resident engaged in hitting, punching, kicking, grabbing, scratching, yelling, and making threats toward other residents. Despite these repeated altercations, the facility did not consistently recognize these events as abuse, nor did they analyze the circumstances or implement effective interventions to prevent recurrence. The facility's own policies required staff to observe, assess, care plan, and monitor residents exhibiting behaviors that could lead to conflict, but these measures were not adequately followed. The resident in question had a documented history of severe cognitive impairment, dementia, and worsening verbal and physical behaviors that interfered with care and placed others at risk. Over several months, this resident was involved in at least 11 documented altercations with 10 different peers, including incidents of physical aggression such as hitting with objects, grabbing, scratching, and verbal abuse. Nursing progress notes and incident logs revealed additional unreported or inadequately investigated incidents, with some resulting in physical injuries to other residents, such as skin tears and scratches. Staff interviews confirmed that the resident's behaviors were unpredictable and escalated quickly, often resulting in fear and distress among other residents. Despite the frequency and severity of these incidents, the facility did not consistently treat verbal altercations as potential abuse unless threats were involved, and physical altercations were not always thoroughly investigated or reported. The care plan interventions implemented, such as 15-minute safety checks and behavioral monitoring, were insufficient to prevent further incidents. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, as required by policy and regulation.
Removal Plan
- Reviewed Resident 19's medications
- Placed Resident 19 on one to one supervision until lower level of care was determined to be appropriate
- Educated all staff to the abuse prevention policies and procedures
- Interviewed all residents to determine feeling safe and secure in the facility