Failure to Prevent Resident-to-Resident Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse, specifically failing to prevent repeated resident-to-resident physical and verbal altercations involving a resident with a history of psychiatric diagnoses, including paranoid schizophrenia, mood disorder, post-traumatic stress disorder, and depression. This resident exhibited ongoing aggressive behaviors, including cussing, making threats to kill staff and other residents, and multiple incidents of physical violence such as kicking and hitting other residents. Despite these repeated incidents, the care plan interventions were not updated with new strategies after each event, and instead, previously implemented interventions were simply relisted. Staff interviews confirmed that the resident's aggressive behaviors were unpredictable and had been ongoing since admission. Documentation showed that after each incident, the resident was either placed on observation, sent for psychological evaluation, or returned from the hospital with no new orders. The care plan coordinator acknowledged that no new interventions were added after continued episodes of aggression, even though the resident continued to display both verbal and physical abusive behaviors. The resident's last psychiatric evaluation was several months prior, and there were no scheduled follow-up appointments, indicating a lack of ongoing psychiatric oversight for a resident with significant behavioral health needs. Another resident, who was the victim of one of the physical assaults, reported being verbally and physically abused by the aggressive resident. This resident, who was moderately cognitively impaired, expressed fear and distress following the incident, stating they were afraid of the aggressive resident and hoped they would not return. The care plan for this resident was updated to allow them to verbalize feelings and receive reassurance, but the primary deficiency remained the facility's failure to implement effective interventions to prevent further abuse and ensure resident safety.