Failure to Protect Residents from Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect multiple residents from abuse, specifically in cases involving resident-to-resident altercations. In one incident, two residents with cognitive impairments and behavioral health diagnoses engaged in a physical altercation in their shared room. Despite both residents expressing fear of each other after the incident, staff did not separate them in accordance with facility policy, and they remained roommates for 48 hours. Both residents sustained visible injuries, including skin tears and bruising, and one resident reported being scared to leave their side of the room. Staff interviews revealed a lack of clear instruction on how to ensure the safety of both residents following the altercation, and the facility's abuse policy requiring immediate separation was not followed. In another event, a cognitively impaired resident entered another resident's room, resulting in a physical altercation. The resident who entered the room was found on the floor with significant facial bruising, a hematoma, and other injuries. The resident's family reported that the resident became increasingly withdrawn and sad following the incident. Staff and LPNs confirmed that the injuries were a result of the altercation, and documentation indicated that the incident was not substantiated as abuse because it was unwitnessed, despite clear evidence of injury and statements from those involved. Additionally, the facility failed to protect several residents from a resident with a known history of verbal and physical aggression. Multiple reports and interviews documented incidents where this resident physically assaulted or attempted to assault others, including punching a resident in bed and attempting to swing at another. Despite these behaviors and the resident's documented history of aggression and mental health issues, the facility did not implement effective interventions to prevent further incidents. All affected residents resided on a locked memory care unit, and the facility census was 259 at the time of the survey.