Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of several residents to be free from abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. In one case, a resident with severe cognitive impairment and a history of Alzheimer's disease was struck in the abdomen and upper body on two consecutive days by another resident with moderate to severe cognitive impairment. Both incidents occurred in the dayroom, with staff intervention occurring only after the altercations had already taken place. Documentation showed that the residents were separated and assessed, but the altercations were witnessed by staff only after the events had begun, and there was a lack of proactive supervision or intervention to prevent recurrence, despite care plans indicating risk for such behaviors. Another incident involved a resident with severe cognitive impairment and behavioral disturbances who was struck on the arm by another resident with dementia and agitation. The altercation occurred in the dayroom and was only noticed by staff after a commotion was heard. Both residents were separated and assessed, but neither could recall the incident shortly after it occurred. The care plans for both residents included interventions for behavioral risks, but the altercation still occurred without immediate staff prevention. A further incident involved a resident with moderate cognitive impairment and multiple comorbidities who was pushed to the floor by another resident with severe cognitive impairment, resulting in a fractured hip. The altercation followed a verbal exchange in the dayroom and was witnessed by staff, but intervention was not immediate enough to prevent injury. The resident who was pushed required hospitalization for the injury. Interviews with staff and the DON confirmed that these incidents met the definition of abuse and did not meet the facility's expectations for resident safety and supervision.