Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of wandering from verbal and physical abuse by another resident. The resident, who had diagnoses including dementia and Alzheimer's disease, was involved in multiple altercations with another resident who also had severe cognitive impairment, hallucinations, and delusions. Despite documented incidents of verbal threats and physical aggression, the care plans for both residents did not adequately address the risk of abuse or specify interventions to prevent further altercations. The facility's investigations confirmed that one resident verbally threatened and later physically assaulted the other, including an incident where staff witnessed the aggressor grabbing and choking the victim. Documentation in the electronic medical records was incomplete, with key incidents not fully recorded or followed up in progress notes. The care plans lacked updates to reflect the ongoing risk, and interventions such as the use of a stop sign barrier were delayed and not consistently implemented. Staff interviews revealed a lack of clear communication and documentation regarding the need for increased supervision and specific interventions to keep the residents apart. Some staff were unaware of the residents' history of altercations or the need for purposeful rounding and redirection. The director of nursing acknowledged that the residents should have been care planned for their risk of abuse, and the nursing home administrator noted deficiencies in timely staff education and documentation following the incidents.