Failure to Protect Resident from Repeated Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from repeated verbal and physical abuse by another resident, despite ongoing incidents and staff awareness. Documentation shows that the abusive behavior began as verbal aggression and threats, escalating over several months to physical abuse, including a witnessed incident where one resident slapped another. Multiple staff members, including CNAs and an LPN, observed and reported these behaviors to administration, but there was no evidence that effective interventions were implemented to prevent further abuse or to separate the residents consistently. The clinical records and staff interviews reveal a pattern of inaction by facility management. Staff reported that incidents were treated as behavioral issues rather than abuse, and management did not respond to staff concerns or implement protective measures. The care plans for the residents involved did not reflect the ongoing aggression, and there was a lack of documentation or follow-up on reported incidents. Additionally, the facility failed to document a physical altercation until several days after it occurred, despite staff and family being aware of the event. The affected resident, who had severe cognitive impairment and was dependent on staff for care, exhibited signs of psychosocial harm following the abuse, including increased agitation and fearfulness, particularly at night. The abusive resident had a documented history of paranoia and aggression toward the victim, but no effective interventions or increased supervision were put in place prior to the escalation to physical abuse. The facility's own policy defined such behaviors as abuse and required protective actions, but these were not followed, resulting in harm to the resident and a failure to uphold resident rights.
Removal Plan
- Resident #2 was assigned a 1:1 sitter and relocated to a different unit, with behavior monitoring
- Resident #1 was assessed for injuries, including possible psychosocial harm. Clinical documentation was reviewed, and behavior was tracked
- Individualized care plans were updated
- Ongoing staff training was implemented on how to identify abuse
- Ongoing staff training was provided on how to intervene and stop abuse
- Ongoing staff training was conducted on the proper protocol for reporting abuse
- All residents were interviewed to identify any potential abuse. For residents unable to be interviewed, the MDS nurse completed an assessment for signs or symptoms of abuse
- Quality Assurance and Performance Improvement (QAPI) meetings were scheduled to review any incidents or concerns related to abuse