Failure to Protect Residents from Physical Abuse and Inadequate Behavioral Care Planning
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, as evidenced by several incidents involving resident-to-resident altercations. In one case, a resident with schizophrenia and a history of behavioral outbursts struck his roommate on the head with a belt buckle, causing a laceration that required emergency room treatment and sutures. The assailant was on one-to-one supervision for elopement risk, but the assigned caregiver was not able to visualize the resident at the time of the incident, as the room door was closed. The caregiver reported not receiving training on one-to-one supervision protocols, and there was no documentation that care plans were reviewed or updated with new interventions following the incident. Another incident involved a resident in the memory care unit who aggressively grabbed and kicked another resident, resulting in both residents sustaining scratches and abrasions. Staff separated the residents and assessed their injuries, but the investigation concluded that physical abuse had occurred, even though neither resident could recall the event. The care plan for the assailant included interventions for behavioral problems, but there was no documentation of a care plan focus for behaviors for the victim, nor was there documentation in the victim's medical record regarding the incident. A third incident involved two residents in the memory care unit who engaged in a physical altercation, resulting in scratches and a skin tear. Staff were unable to determine what precipitated the altercation, and there was no documentation in the medical record for one of the residents regarding the incident. Additionally, the care plan for one of the residents did not include a focus on behaviors, despite the occurrence of the altercation. Across these incidents, the facility failed to ensure that care plans were reviewed and updated for effectiveness, and staff lacked adequate training and documentation to prevent and respond to resident-to-resident abuse.