Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse by another resident who also had severe cognitive impairment and a history of wandering and aggressive behaviors. On the date of the incident, a CNA observed one resident in another resident's room, placing a pillow over the resident's head while the resident was in bed. The CNA intervened by removing the resident and notifying the charge nurse immediately. Prior to the incident, the resident who committed the act was known to wander frequently, enter other residents' rooms, get into other residents' beds, and display aggressive behaviors such as hitting at staff. The behavioral care plan for the resident with wandering and aggressive behaviors included interventions such as encouraging activities, providing materials for independent activities, and using a calming voice during disruptive behaviors. However, these interventions did not address the resident's constant wandering and entry into other residents' rooms. Staff interviews confirmed that the resident was difficult to manage and that the behaviors were ongoing, with staff offering activities or food as redirection, but without effective supervision to prevent incidents. The facility's policy required identification of residents at risk for abusive or aggressive behavior and the development of appropriate intervention strategies to prevent occurrences. Despite this, the facility did not provide adequate supervision or interventions to prevent the resident with a known history of wandering and aggression from accessing other residents' rooms and perpetrating physical abuse. The facility's investigation substantiated that the incident occurred but did not classify it as abuse due to both residents' cognitive impairments.