Failure to Prevent Resident-to-Resident Physical Abuse Amid Escalating Behaviors
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was cognitively intact and had a history of stroke with paralysis on one side, was kicked in the shin by another cognitively intact resident while waiting in the hallway for a cigarette. The incident did not result in pain, injury, or mental anguish for the victim, but it was a physical altercation that was reported to staff. Prior to the incident, the resident who committed the abuse exhibited escalating behavioral issues, including increased agitation, verbal outbursts, refusal of medications, and disruptive actions such as throwing items and making threats. Documentation in the progress notes indicated that these behaviors were observed and recorded by staff over the course of at least two days, with specific episodes of agitation, wandering, and aggression noted. Despite these documented behaviors, there was no evidence in the electronic health record that interventions were changed or increased to address the resident's escalating behavior or to prevent potential harm to others. The facility's own policy required ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, including the implementation of appropriate interventions to prevent abuse. However, interviews and record reviews confirmed that the facility did not increase supervision or modify interventions for the resident exhibiting aggressive behaviors, even after multiple incidents and the physical altercation occurred.