Failure to Revise Care Plans After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to revise care plans to address supervision and behavioral interventions following a resident-to-resident abuse incident involving two residents with severe cognitive impairment. One resident, diagnosed with Alzheimer's Disease, anxiety, and depression, and another resident with dementia, both scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The second resident exhibited physical behavioral symptoms toward others, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others every 4 to 6 days, as documented in the medical record. On a specific date, the second resident groped the first resident's breast, which was witnessed by staff. The first resident responded by repeatedly slapping the second resident's shoulder, stating that the action was to make the other resident stop. Despite this incident, a review of the care plans for both residents revealed that no new interventions or revisions were made to address the incident or to prevent recurrence. The Director of Nursing confirmed that no changes had been made to the care plans following the event.