Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents where one resident with dementia and psychotic disturbances physically assaulted three other residents. The facility's abuse policy requires that residents remain free from abuse, neglect, and corporal punishment, but records show that this was not upheld. In each case, the aggressor resident initiated physical altercations, including kicking and slapping, against other residents who had diagnoses such as dementia, muscle weakness, and major depressive disorder. These incidents were reported and investigated, with the aggressor consistently identified as the source of abuse. Despite care plans and physician orders directing staff to monitor the aggressive resident closely, document behaviors, and intervene as necessary, there were repeated failures to implement or document appropriate interventions. Behavior monitoring records indicated multiple episodes of physical aggression without corresponding interventions, and in some cases, incidents of aggression were not documented in the resident's record at all. Staff interviews confirmed that interventions were either not carried out or not documented, and that staff missed opportunities to intervene when the resident became agitated. The lack of consistent monitoring, failure to implement or document required interventions, and inadequate response to escalating behaviors directly contributed to the ongoing risk and occurrence of resident-to-resident abuse. The facility's inaction and insufficient documentation allowed the aggressive behaviors to persist, resulting in repeated physical altercations and a failure to ensure a safe environment for all residents involved.