Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
A deficiency occurred when a resident with a known history of aggressive behavior and a need for supervision struck another resident on two separate occasions. The first incident took place in the foyer while a staff member was assisting the aggressive resident to smoke; the staff member turned away momentarily to open a door, during which time the resident struck another resident. The second incident occurred when the same resident approached and punched the same individual in the head while the latter was talking to staff. In both cases, staff were present but unable to intervene in time to prevent the physical altercations. The resident who was struck had significant cognitive impairment, hemiplegia, hemiparesis, intellectual disabilities, and schizoaffective disorder. This resident exhibited both physical and verbal behavioral symptoms, but was the victim in these incidents. The aggressive resident had moderate cognitive impairment, schizophrenia, anxiety disorder, and a history of delusional thinking and paranoia. This resident had documented behaviors directed toward others and was on psychotropic medications. Despite these known risks, the care plan for the aggressive resident did not address behaviors directed toward others or include specific monitoring for incident prevention. Staff interviews revealed that while the aggressive resident was monitored and had some restrictions, there were no particular interventions in place to prevent altercations between the two residents. Staff were aware of the history of conflict between the two, but no care plan interventions were documented to address or mitigate the risk of further incidents. The lack of a targeted care plan and failure to implement preventive measures contributed to the recurrence of resident-to-resident altercations.