Failure to Prevent Resident-to-Resident Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents of resident-to-resident physical altercations involving three residents. One resident with a history of hemiplegia, vascular dementia, and anxiety disorder exhibited ongoing aggressive behaviors, including hitting, biting, and fighting with other residents. Despite documentation of these behaviors and repeated altercations, the facility did not implement new or adequate interventions to address the escalating aggression. The care plans for the involved residents were not updated with additional strategies, and the only documented interventions were continued 15-minute checks and minor environmental changes, such as removing a footboard. Another resident, diagnosed with paranoid schizophrenia and severe cognitive impairment, was also involved in multiple physical altercations, including an incident where he struck another resident, resulting in a head laceration that required sutures and hospital admission. This resident demonstrated a pattern of aggression toward both staff and other residents, with progress notes indicating repeated episodes of hitting, yelling, and being difficult to redirect. Despite these behaviors, the facility did not conduct interdisciplinary team (IDT) reviews or psychological re-evaluations to determine appropriate interventions, nor did they screen or interview other potentially affected residents. Staff interviews and documentation revealed that the facility's response to these incidents was limited to immediate separation of residents and continued monitoring, without comprehensive reassessment or implementation of new interventions. The nursing home administrator and DON acknowledged that care plans and interventions were inadequate and that there was a lack of new strategies to prevent further aggressive occurrences. Additionally, staff reported concerns about unsafe staffing assignments, which were not addressed by facility leadership. The facility's own policy required increased supervision and protection from harm, but this was not consistently or effectively implemented.