Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from physical abuse, resulting in one resident physically assaulting another. The incident involved a male resident with schizophrenia and autism, who had a documented history of aggressive behaviors, including hitting, biting, and throwing objects at both staff and other residents. Despite multiple documented episodes of aggression in the weeks leading up to the incident, no new interventions or increased supervision were implemented to address the escalating behaviors. On the day of the incident, the aggressive resident exited his room and struck another male resident, who was cognitively intact and using a wheelchair, in the face. Staff interviews confirmed that there was no staff present in the hallway or at the nurses' station at the time of the assault, and that the aggressive resident was able to approach and hit the other resident without intervention. The assaulted resident sustained redness to his cheek, and the aggressor incurred a minor laceration from contact with the wheelchair. Prior to the assault, the aggressive resident had also thrown a drink at another resident, but the facility did not increase supervision or implement additional safety measures following this event. The care plan for the aggressive resident noted his history of physical aggression but was not updated with new interventions after repeated incidents. Documentation also revealed that required 15-minute checks, which were eventually added to the care plan, were not consistently performed or documented.
Plan Of Correction
Resident #102 still resides in the facility. The resident has not had any further encounters with other residents and continues to show no signs of distress from the 5/12/25 and 6/17/25 incidents. Resident #101 still resides in the facility and has not had any further issues of aggression with other residents. Facility residents have the potential to be affected by the alleged deficient practice. The Social Services Director/designee completed facility-wide interviews with residents to ensure there were not any unaddressed concerns on 7/1-7/3/25. Any discrepancies noted with the interviews were addressed at that time. The Staff Development Coordinator/Designee will provide re-education to all staff on the facility abuse prevention policy and de-escalation tips for challenging behaviors on or before 7/14/25. Staff will not be allowed to work until education is completed. The IDT will review 24-hour reports for resident-to-resident encounters for potential abuse. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. The Social Service Director/Designee will audit resident concerns to review for potential abuse allegations during IDT meetings. This audit will be conducted three days a week for eight weeks or until substantial compliance is achieved. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Executive Director is responsible for ongoing compliance.