Failure to Protect Residents from Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from physical abuse and neglect in two separate incidents involving residents with severe cognitive impairment. In the first incident, a male resident with severe dementia, depression, and a history of wandering and physical aggression was involved in an altercation with a family member (FM) visiting another resident. The resident, who had a BIMS score indicating severe cognitive impairment and a care plan noting lack of awareness of personal boundaries, became agitated and physically struck the FM. The FM responded by hitting the resident in the face, resulting in visible bruising. Staff interviews and documentation confirmed that the resident was not adequately supervised at the time, and the altercation was not prevented. In the second incident, another resident with severe cognitive impairment and a history of wandering entered the room of a different resident. The resident whose room was entered responded by physically striking the wandering resident after a verbal exchange. Staff observed the incident and separated the residents, but the event was initially treated as a general incident rather than as potential abuse or neglect. The care plans for both residents did not adequately address the risk of resident-to-resident altercations, and staff interviews revealed inconsistent understanding of how to identify and report abuse in such situations. Both incidents demonstrate failures in supervision and in the implementation of care plans designed to address known behavioral risks. The facility did not ensure that residents with a history of wandering and aggression were adequately monitored or that interventions were in place to prevent altercations with other residents or visitors. Documentation and interviews indicate that staff were aware of the residents' behavioral histories but did not take sufficient action to prevent or immediately recognize abuse and neglect when it occurred.