Failure to Implement Abuse Policy Following Resident-on-Resident Incident
Penalty
Summary
A resident with multiple medical conditions, including morbid obesity, intracerebral hemorrhage, and an above-knee amputation, reported being struck multiple times by another resident while in bed. The incident was documented by nursing staff, who assessed the resident and found no visible injuries. Despite the resident expressing emotional distress, flashbacks, and a lack of safety following the event, there was no evidence that facility staff provided emotional support, counseling, or a psychosocial assessment as outlined in the facility's abuse policy. The resident also reported to a nurse practitioner that he was afraid to sleep and later was found to have kept scissors under his pillow for self-protection, but this information was not communicated to the social worker or acted upon for further psychological evaluation. The facility's policy required protection of the resident and specific reporting and response actions following allegations of abuse, including examination for injury, emotional support, care plan revision, and timely reporting to appropriate authorities. However, the social worker confirmed that she did not follow up with the resident after the allegation, and there was no documentation of a psychological evaluation or referral. Additionally, the nurse practitioner did not report the resident's ongoing fear or the presence of scissors to the rest of the care team. These failures indicate that the facility did not fully implement its abuse prevention and response procedures after the resident's allegation.