Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in multiple resident-to-resident altercations and incidents of physical and verbal aggression. Several residents with varying degrees of cognitive and physical impairment were involved in these incidents. For example, one resident with bipolar disorder, impulse disorder, and Parkinson's disease was involved in multiple altercations, including fighting with another resident in the smoking area, being hit with a walker by a different resident in the dining room, and kicking a resident with severe cognitive impairment during breakfast. These events were often preceded by arguments, verbal aggression, or behaviors such as instigating conflicts and making inappropriate comments. Another resident with vascular dementia and hemiplegia was involved in a physical altercation in the smoking area, where both he and another resident ended up on the ground after an argument escalated. The care plans for these residents included interventions such as monitoring for signs of danger, psychological evaluations, and staff supervision, but these measures were not effective in preventing the altercations. In one case, a resident with severe cognitive impairment and hemiplegia was threatened and grabbed by another resident, and later kicked by a different resident, despite care plan interventions intended to prevent such incidents. Interviews with residents and staff revealed a pattern of ongoing behavioral issues, with one resident frequently instigating arguments and being verbally aggressive toward others. Staff and residents reported that this individual had a history of behavioral problems, including being physical with other residents and making inappropriate comments. Despite being aware of these behaviors and having care plans in place, the facility did not prevent repeated incidents of abuse and altercations among residents, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- All staff in-serviced by Executive Director of Operations (EDO)/Director of Clinical Operations (DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident. All staff not present at time of in-service will not be permitted back to work until in-service is complete.
- Resident #3 was placed on one-to-one monitoring. Discharge Planning initiated to family. Resident remained on one-to-one monitoring until discharge.
- Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Action taken based on survey results, including care plan and task updates and one-on-one in-service for CNA as needed.
- All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services.
- The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting.
- Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with any investigation documentation attached.
- All staff in-serviced on the Grievance process and utilizing the Grievance form to document the potential abuse or situation and the investigation.
- The Medical Director was made aware of the immediate jeopardy and involved in the development of the plan to remove during an abbreviated QA. Next scheduled QA meeting set.
- Monitoring of the Plan of Removal will be conducted through personal observation, through completion by Regional President of Operation and Regional Director of Clinical Services.