Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents on the secure unit from abuse by not developing and implementing effective interventions for a resident with a history of aggressive behaviors. This resident, who was severely mentally impaired and had diagnoses including seizure disorder, traumatic brain injury, psychotic disorder, and schizophrenia, exhibited daily physical behavioral symptoms such as hitting, kicking, pushing, and wandering. Multiple documented incidents showed the resident initiating altercations with other residents, including hitting, knocking down, and jumping on others, often without adequate follow-up or assessment of the affected residents. Staff did not consistently document interventions or notify providers after these altercations, despite facility policy requiring such actions. In several cases, there was no record of assessment or status for the recipients of the altercations, and provider notification was missing for specific incidents. Interviews with staff revealed a general awareness of the resident's aggressive tendencies, but also indicated that staff were sometimes left alone on the unit, resulting in the resident being left unattended and able to enter other residents' rooms unsupervised. Additionally, standing orders provided to staff did not address agitation or aggression, and a behavioral health evaluation ordered for the resident had not been completed due to leadership and resource issues. The lack of timely provider notification, incomplete documentation of interventions, and failure to implement effective behavioral management strategies contributed to repeated altercations and placed all residents on the secure unit at risk.