Failure to Protect Resident from Abuse Due to Inadequate Behavioral Assessment and Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another out of her wheelchair, resulting in the latter falling to the floor. The facility's policy requires the identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect. However, the admission team did not identify that the resident who committed the abuse had Bipolar II disorder or that he had been receiving psychological care at his previous facility. There were no behavioral health care plans in his record, nor were any mental health appointments provided to him after admission. The resident had a history of aggression, agitation, and suicidal ideation, as documented in multiple progress notes, and was placed on 1:1 monitoring after expressing self-harm and aggressive behaviors. Despite being under continuous 1:1 monitoring, the resident was able to approach another resident in the hallway and push her out of her wheelchair. The interdisciplinary team did not meet to discuss the altercation until six days after the event. The resident who was pushed had severe cognitive impairment and was significantly dependent on caregivers. The Director of Nursing confirmed gaps in the identification and care planning for the resident with behavioral health needs, as well as a lack of awareness of his mental health status and history upon admission.