Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically physical abuse and altercations between residents, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral histories. In one incident, two residents with dementia and histories of agitation and aggression engaged in an altercation at a lunch table, where one resident threw water at the other. Both residents had documented behavioral care plans, but the care plan for the resident who was the victim did not indicate a risk for abuse or prior victimization. The incident was witnessed by a CNA, and both residents were subsequently monitored, but the event itself was substantiated as it occurred. Another incident involved a resident entering another resident's room and physically kicking her after being asked to leave. The assailant had a documented history of wandering, intrusiveness, and physical aggression, with care plan interventions focused on redirection and monitoring. However, after the physical altercation, the care plan did not reflect new interventions specific to the incident. The event was witnessed by a CNA, and the victim was checked for injury, but the documentation did not indicate a comprehensive assessment for injury at the time of the incident. A further altercation occurred when one resident verbally provoked another, resulting in the provoked resident slapping the other in the face. Both residents had severe cognitive impairments and behavioral symptoms, with care plans addressing their aggression and agitation. The incident was witnessed by both an RN and a CNA, and the residents were separated. The documentation confirmed that neither resident recalled the incident, but the physical contact was substantiated. These events demonstrate that the facility did not prevent or adequately address resident-to-resident physical abuse, as required by policy.