Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical assaults, resulting in nine incidents involving one resident physically assaulting eight other residents over a four-month period. The resident responsible for the assaults had a history of mental health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation, and was known to have moderate cognitive impairment. Despite repeated incidents of aggression, the facility did not implement new or effective interventions after the initial care plan was created, nor did they update the care plan to address the ongoing behaviors. Documentation shows that after each incident, staff separated the residents involved, assessed for injuries, and noted that they would monitor and intervene if further behaviors were observed. However, there was no evidence of increased monitoring, special precautions, or additional interventions being put in place for the resident exhibiting aggressive behaviors. Interviews with staff confirmed that the resident was not on any special monitoring or precautions, and staff were not aware of any specific changes to the resident's care plan to address the repeated assaults. The facility's policy required staff to monitor for aggressive behavior, make necessary changes to care plans, and transfer residents if care could not be provided safely. Despite this, the care plan for the resident in question was not updated after multiple incidents, and interventions remained unchanged and ineffective. The lack of timely and appropriate action to address the resident's escalating behaviors resulted in continued physical assaults on other residents.