Failure to Protect Resident from Verbal and Physical Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident was not protected from verbal and physical abuse by another resident. Specifically, one resident with a history of schizophrenia, psychoactive substance abuse, and visual hallucinations verbally assaulted another resident by yelling and calling him derogatory names, then physically assaulted him by striking him on the head with a closed fist. The aggressor continued to chase the victim down the hallway until staff intervened and separated the two individuals. Both residents were cognitively intact according to their most recent assessments. The facility's policy required all appropriate preventative measures to ensure residents are not at risk for abuse, but this was not followed in this instance. The assaulted resident, who had a history of schizoaffective disorder, bipolar type, and self-reported anxiety, reported feeling upset and experiencing tenderness in his head following the incident. The event resulted in increased anxiety and the potential for emotional stress for the resident who was attacked.
Plan Of Correction
The facility recognizes the importance of maintaining an environment that is free from abuse and neglect. The facility will continue to maintain an environment that is free of abuse and neglect. The facility intervened immediately when the incident involving Resident 56 occurred. Resident 38, the aggressor in this incident, was transferred to a different level of care immediately after the incident. Resident 38 will not return to the facility. The facility initiated a Care Plan on 5/24/25 to monitor Resident 56 for "feelings of being unsafe through the next review date." Interventions attached to the Care Plan included "Encourage Resident 56 to inform staff if he is feeling unsafe," "Provide Resident 56 with 1:1 contacts as needed for emotional support," and "Support Resident 56 with pro-social outlets to encourage feelings of safety in the milieu." Resident 56 was placed on routine monitoring immediately after the incident, with frequent Progress Notes reflecting his comfort, levels of anxiety, and safety. 5/24/25 0239 - "Resident was counseled on staying safe and letting us know if he is being bothered" 5/24/2025 0557 - Nurse Note "Resident has not shown any s/s of emotional distress" 5/24/2025 0851 - Alert Note "Resident denies any pain or discomfort" 5/24/2025 1302 - Nurses Note "No complaints of pain or discomfort" 5/24/2025 1428 - Welfare Check "No noted issues this shift. No statements of feeling unsafe" 5/24/2025 1514 - Program Note "Resident stated he is feeling fine... The writer encouraged Resident to seek staff if he felt unsafe" 5/24/2025 1538 - Welfare Check "Feeling fine, a little better". Asked if he has concerns about safety, he stated "No I think it was a one off, he even apologized to me" 5/24/2025 - Welfare Check "Had an okay day" and felt safe in the facility 5/24/2025 2209 - Welfare Check "I am doing good and feel safe here" 5/25/2025 1356 - Nurses Note "Compliant with neuro checks... no c/o pain or discomfort and this time" 5/25/2025 1528 - Nurses Note "Stated they felt safe at this time" 5/25/2025 2145 - Asked if he is okay "Yes, I am happy here. I feel good. I am okay" 5/26/2025 0618 - Welfare Check "Client has not made any statements of distress or feeling unsafe" 5/26/2025 1407 - Welfare Check "No noted issues or statements of feeling unsafe" 5/27/2025 0939 - IDT Note "Did not wish to discuss the incident further... Did not report feeling unsafe through the weekend... Did not express any s/s of distress... will be discontinued from welfare checks due to not expressing feeling unsafe" 5/28/2025 1722 - IDT Note "Ombudsman met with Resident 58... Resident denied feeling unsafe and had no concerns at the time of the interview" Facility will continue to provide Elder and Dependent Adult Abuse education as part of the new hire orientation for newly hired staff. Facility will continue to provide Elder and Dependent Adult Abuse in-service education to staff through the year as part of the facility's annual educational calendar. Facility DSD began providing in-services to staff on 6/4/2025, including guidelines and expectations of maintaining a facility free of abuse and neglect. As part of the facility admission process, the Admission Coordinator will screen for residents with a history of abuse or assaultive behavior towards others. Further issues regarding Resident Abuse will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Administrator, Director of Nursing, DSD, Medical Director, department heads, leadership team, nursing staff, and all departments shall be responsible to monitor for ongoing compliance.