Failure to Protect Residents from Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse and did not ensure appropriate interventions or documentation were in place following incidents involving multiple residents. One resident with schizoaffective disorder and mild cognitive impairment reported being grabbed inappropriately by another resident with a history of behavioral disturbances. Although the accused resident was supposed to be under line-of-sight monitoring due to recent manic behaviors, the facility could not provide documentation to confirm this monitoring occurred. Additionally, the care plan for the resident exhibiting aggressive behaviors was not updated with new interventions after each incident as required. Another incident involved a resident with vascular dementia and behavioral disturbances being hit in the face by the same resident with behavioral issues. This event was witnessed by a staff member, and the police were notified. The resident responsible for these behaviors had a documented history of verbal and physical outbursts, including yelling, cussing, hitting walls, and instigating altercations with peers. Despite repeated disruptive and aggressive behaviors, the facility's documentation showed only attempts at redirection and medication adjustments, with no evidence of effective interventions or consistent monitoring to prevent further abuse.