Failure to Prevent Resident-to-Resident Abuse and Ensure Resident Safety
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving physical and verbal aggression. One cognitively intact resident with a history of delusions, daily behavioral symptoms, and worsening aggression was involved in several altercations. This resident struck another cognitively intact resident in the face with an object and a cup of water, resulting in a visible bruise and discomfort for the victim. The incident was witnessed by an LPN, and the aggressor had recently been removed from 1:1 supervision. The victim reported feeling unsafe and uncomfortable in the facility, and had previously received verbal threats from the aggressor. Additional incidents included verbal and physical altercations between residents, such as one resident yelling, cursing, and threatening another, which escalated to the throwing of a cup of ice and physical intimidation. Another resident reported being subjected to physical aggression, including having cold coffee thrown on him while sleeping, and described ongoing verbal abuse and theft of personal items by his former roommate. This resident expressed feeling unsafe and mistrustful of the aggressor. Other altercations involved racial slurs, threats of violence, and the brandishing of a butter knife, which was retrieved by staff after being observed by a visitor. Care plans for several residents did not document risks for abuse, despite known behavioral histories and previous incidents. The facility's policies state a commitment to protecting residents from abuse by anyone, and staff are responsible for providing a safe environment. However, the repeated incidents of physical and verbal aggression, lack of effective interventions, and failure to update care plans to address abuse risks contributed to the deficiency in protecting residents from abuse and ensuring their safety.