Failure to Implement Interventions to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement interventions to prevent further resident-to-resident abuse incidents, as evidenced by two residents involved in an altercation. One resident with a history of anxiety, fluctuating moods, and suicidal ideation exhibited escalating behaviors, including verbal threats and expressions of self-harm, prior to the incident. Despite these documented behaviors and interactions with nursing staff regarding pain management and mental health concerns, no additional interventions were put in place to address the resident's risk of aggressive behavior toward others. The deficiency was identified when the resident physically assaulted another resident, resulting in facial injuries. Facility policies required immediate and effective measures to prevent further abuse while investigations were ongoing, but the only action taken prior to the incident was the resident's arrest after the assault. The administrator confirmed that no other interventions were implemented to prevent further potential abuse between residents.