Failure to Prevent Resident-to-Resident Mistreatment Due to Inadequate Behavioral Interventions
Penalty
Summary
A resident with severe cognitive impairment, functional mobility deficits, and a history of agitation was involved in a resident-to-resident altercation. The resident, who was non-ambulatory and used a wheelchair, was seated in their room when another resident entered, refused to leave when asked, and then slapped the first resident in the face. The incident was documented, and the resident was assessed with no injuries found. The resident who initiated the altercation had a diagnosis of Alzheimer's disease with mood disturbance and a documented history of wandering into other residents' rooms, agitation, and both verbal and physical aggression toward staff and others. Despite repeated documentation of these behaviors over several months, the care plan did not initially address the resident's wandering or adequately mitigate the risk of aggressive behaviors toward other residents. The care plan was only revised to include interventions for wandering and 1:1 monitoring after the altercation occurred. Staff interviews revealed that the aggressive resident often refused medications, which impacted their behavior, and that family members were sometimes called to assist with redirection. Facility policy indicated that abuse investigations were not completed for staff assaults unless injury occurred. The failure to address the resident's wandering and aggressive behaviors in the care plan and to implement effective interventions led to the incident of resident-to-resident mistreatment.