Failure to Prevent Resident-to-Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to prevent resident-to-resident abuse for two of four residents reviewed for abuse. In one incident, a resident with severe cognitive impairment, metabolic encephalopathy, and Parkinson’s disease, who was known to crawl on the floor and wander, attempted to enter another resident’s room. The second resident, also severely cognitively impaired and with a history of behavioral disturbances, kicked the first resident in the face multiple times, resulting in significant injuries including contusions, lacerations, and bruising. At the time of the incident, only one staff member was present on the secure unit, and there were no interventions in place to prevent the first resident from entering other residents’ rooms, despite known wandering behaviors. Staff interviews confirmed that the resident had been crawling around the unit since admission and that staffing levels were insufficient to monitor all residents effectively. In a separate incident, a resident with a history of traumatic brain injury, stroke, and moderate cognitive impairment sustained a laceration and a linear skull fracture after an unwitnessed event in their room. The resident reported being struck on the head by another resident, who was later seen with a razor in hand. Staff discovered the injury after hearing a commotion, and both residents involved reported that the injury was caused by the other. The facility did not immediately complete an incident report, and there was confusion among staff regarding the cause of the injury, with explanations ranging from a razor cut to being struck with a metal object. Documentation and neurological checks were lacking, and the incident was not initially logged or reported as required. Both incidents involved residents with significant cognitive and behavioral challenges residing on a secure unit. The facility’s care plans and interventions did not adequately address the risks of resident-to-resident altercations, particularly for residents with known wandering or aggressive behaviors. Staff interviews revealed gaps in supervision, incident reporting, and follow-through on required documentation, contributing to the failure to protect residents from abuse and neglect as required by facility policy and federal regulations.