Failure to Protect Residents from Abuse and Inadequate Supervision of Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a cognitively intact resident reported that a staff member threatened to remove them from the facility following a resident-to-resident altercation. The resident became visibly upset, exhibited behavioral changes, and withdrew from activities. The facility's investigation confirmed that the staff member had verbally and emotionally abused the resident. In the second incident, a resident with dementia and a history of aggressive and agitated behaviors repeatedly exhibited physical aggression toward other residents and staff. Despite multiple documented episodes of aggression, including hitting, biting, and making threats, as well as being sent to the hospital for these behaviors, there was no evidence that the facility increased supervision or updated the care plan with new interventions upon the resident's return. The resident continued to display aggressive behaviors, culminating in an incident where the resident physically assaulted another resident, resulting in injury. Throughout the period reviewed, documentation failed to show that the primary care or psychiatric providers were consistently notified of the resident's escalating behaviors, nor was there evidence of orders for increased supervision or implementation of 1:1 monitoring as an ongoing intervention. The care plan addressing aggressive behavior was not updated after significant incidents, and staff interviews confirmed that increased supervision was not documented or ordered following hospitalizations for aggressive behavior.