Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a substantiated incident of abuse. According to the facility's own Abuse Prohibition policy, staff and residents were to be educated on avoiding situations that could lead to abuse, and proactive rounding was to be implemented to identify potential triggers and wandering behaviors. Despite these policies, a resident with a history of wandering and physical aggression was able to access hot coffee unsupervised and enter another resident's room, where she threw the coffee on the other resident, causing a red area on his right elbow. The resident who committed the abuse had severe cognitive impairment, Alzheimer's disease, and dementia, and was known to wander, invade personal space, and throw food items at others. Her care plan included interventions such as placing door signs, assisting her to designated areas, redirecting her when wandering, and ensuring she was closely supervised when consuming coffee. However, on the day of the incident, staff assisted her out of bed early and she wandered to another resident's room before staff were available to monitor her, leading to the altercation. The victim, also with severe cognitive impairment and multiple psychiatric and neurological diagnoses, was independent with mobility and had no prior behavioral symptoms. After the incident, he was found to have a red area on his arm but denied pain or discomfort. The facility's investigation confirmed that staff were not monitoring the resident with known behavioral risks at the time of the incident, which directly contributed to the occurrence of physical abuse.