Failure to Assess, Document, and Notify Physician After Resident-to-Resident Abuse and Aggression
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards for three residents following incidents involving inappropriate touching and physical aggression. In the first case, a resident with a history of depressive disorder, schizophrenia, and cognitive decline was inappropriately touched by another resident. The charge nurse observed the incident and confirmed that the resident expressed discomfort and fear, yet there was no documentation of the event, no assessment or monitoring of the resident's physical, emotional, or mental status, no care plan developed to address the incident, and the physician was not notified. The resident reported feeling unsafe and scared, and only one staff member spoke to her about the incident. In the second case, another resident with diabetes, osteoarthritis, and polyneuropathies was punched in the chest multiple times by the same aggressor in an elevator. Despite staff being aware of the incident, there was no documentation in the medical record, no assessment for injuries, no monitoring for 72 hours post-incident, no care plan addressing the event, and the physician was not notified. The resident confirmed the physical altercation, and staff interviews revealed that required documentation and follow-up were not completed. The third resident, who was the perpetrator in both incidents, had diagnoses of dementia, depressive disorder, and anxiety disorder. There was no documentation of his involvement in the incidents, no assessment or monitoring of his behavior, no care plan to address his inappropriate and aggressive actions, and no physician notification. Interviews with facility leadership and review of policies confirmed that the facility's procedures for change of condition, abuse prevention, and documentation were not followed for any of the three residents involved.