Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by an incident in which one resident with severe cognitive impairment, agitation, and aggressive behavior physically struck another resident. The care plan for the aggressive resident included interventions such as separating them from stressful situations and monitoring for signs of frustration, but these measures did not prevent the incident. The resident's assessment documented daily verbal behavioral symptoms and significant risk for physical illness or injury due to their condition. Following the incident, the resident who was struck was found to have slight redness behind the left ear and expressed concern about being hit again, despite stating they felt safe overall. The Director of Nursing (DON) was not aware of the incident at the time of interview and confirmed that an incident report had not been completed or reported to the state health department as required. The facility's policy prohibits all forms of abuse, but the failure to implement and follow reporting procedures contributed to the deficiency.