Failure to Protect Residents from Aggressive Behavior Due to Inadequate Implementation of Care Plan
Penalty
Summary
The facility failed to protect residents from aggressive behavior exhibited by a resident with Alzheimer's disease and dementia with behavioral disturbance. This resident had a documented history of striking, spitting, grabbing, refusing care, and throwing objects, with behaviors escalating in areas of increased stimulation or congestion. Despite these known behaviors and a care plan intervention to remove the resident from overstimulating environments, staff were unable to consistently articulate or implement the care plan strategies to manage the resident's aggression. On two separate occasions, the resident became physically aggressive with other residents. In one incident, the resident hit another resident when their wheelchairs became stuck together in a hallway. In another, the resident struck a different resident with a piece of paper while being moved through a congested area. Staff present during these incidents attempted to manage the situation but were unable to prevent the aggressive acts. Interviews with staff revealed a lack of familiarity with the resident's specific triggers and care plan interventions, with several staff members stating they simply tried to keep a close eye on the resident or distract her when agitated. Record review and staff interviews confirmed that the care plan included removing the resident from areas of increased stimulation to minimize agitation, but this intervention was not consistently followed. The facility's abuse and neglect policy required staff to be knowledgeable about residents' care needs and appropriate interventions for aggressive behaviors, but staff assignments changed daily and not all staff were aware of or able to verbalize the care plan. Leadership discussed the resident's behavior after the incidents, but there was no clear plan communicated to manage the aggression toward other residents.