Failure to Prevent Resident-to-Resident Physical Abuse Due to Incomplete Care Planning
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, as required by its abuse prevention policies. An incident occurred in the dining room where one resident reported being kicked, grabbed, and hit on the chest by another resident while walking to dinner. In response, the first resident struck the second resident in self-defense. Staff did not witness the event, and it was not captured on facility cameras. The incident resulted in a minor injury—a bruise above the left eye of one resident—and damage to his eyeglasses. Both residents involved had documented cognitive impairments and behavioral issues. One resident had a diagnosis of dementia, was cognitively intact per recent assessment, and had a care plan addressing agitation and physical outbursts. The other resident had moderate cognitive impairment, dementia, and a history of making uninvited sexual advances and explicit comments, with care plans for behavioral monitoring and antipsychotic medication. Despite these documented risks, the care plan intervention to assist the second resident to an appropriate table in the dining room to prevent collisions with other residents was not included in the resident's Kardex, which is the primary tool used by CNAs for care guidance. Staff interviews revealed that CNAs relied on the Kardex for resident-specific interventions and were unaware of the missing intervention for the second resident. The assistant director of nursing confirmed that the intervention to assist the resident to an appropriate table had not been added to the Kardex at the time of the incident. This omission contributed to the failure to prevent the altercation between the two residents, as staff were not adequately informed or equipped to implement the necessary preventive measures.