Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents of resident-to-resident physical altercations involving four residents. One resident with diagnoses including schizophrenia, traumatic brain injury, and epilepsy exhibited repeated aggressive behaviors, including entering other residents' rooms, physical altercations, and wandering. Despite documentation of these behaviors in nursing progress notes and care plans, the resident was not consistently placed on one-to-one monitoring at the time of the incidents, and interventions were not sufficiently updated to address the ongoing risk. Several specific incidents were documented: one resident was injured after being struck in the face by another resident who entered their room, resulting in lacerations that required emergency medical care. Another incident involved a resident being punched in the face while an item was taken from their walker, causing injury. Additional altercations included a resident being punched after attempting to prevent another from entering their room, and a forceful push that resulted in two residents falling to the floor. These events occurred despite existing care plans that identified behavioral symptoms and interventions such as medication management, safety checks, and environmental modifications. The facility's policies required immediate action to stop abuse and prompt reporting, as well as comprehensive care planning for residents at risk. However, there was no documented evidence of a care plan specifically addressing risk for abuse for at least one resident before or after a significant incident. Staff interviews indicated challenges in providing adequate supervision due to staffing issues and a high population of residents with behavioral health needs. The facility also faced difficulties in discharging residents to more appropriate settings, and there were gaps in communication regarding residents' behavioral histories upon admission.