Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically attacked another. A resident with diagnoses including schizophrenia, mood disorder, and other medical conditions exhibited erratic mood swings, auditory hallucinations, and aggressive behaviors over several days. Despite these behaviors being documented in the Medication Administration Record (MAR), there was no detailed description of the behaviors or documentation of staff interventions. The facility did not implement its own Abuse Prevention/Prohibition policy, which required understanding and monitoring behavioral symptoms that could increase the risk of abuse, such as aggression and outbursts. There was no individualized care plan addressing the resident's schizophrenia, nor were interventions developed to monitor and re-evaluate the effectiveness of behavioral management strategies. The existing care plans for psychosocial well-being and mood patterns were not followed, as there was no documentation that staff listened attentively or addressed the resident's concerns during periods of erratic mood swings and hallucinations. Staff interviews revealed that aggressive and disruptive behaviors were observed but not consistently reported or documented, and there was a lack of communication among staff regarding these behaviors. As a result of these failures, the resident with schizophrenia physically assaulted another resident, causing visible injury, pain, and emotional distress. The assaulted resident expressed feeling unsafe and fearful of being alone, and required pain medication for the injuries sustained. The incident was witnessed by staff, and subsequent interviews confirmed that the aggressive behaviors had been ongoing and inadequately managed, with insufficient documentation and monitoring to prevent harm.