Failure to Prevent Resident-to-Resident Abuse and Address Behavioral Risks
Penalty
Summary
The facility failed to protect two residents from abuse when they became involved in a physical altercation. One resident, who had moderate cognitive impairment and diagnoses including major depressive disorder and heart failure, did not receive their prescribed Trazodone for three consecutive days. This medication was intended to address depression and insomnia, and the lack of administration was not documented or explained in the Medication Administration Record. Staff interviews confirmed that missing this medication could result in restlessness, agitation, or other safety concerns, and there was no evidence that adverse effects or side effects were being monitored during this period. Another resident, with severe cognitive impairment and a history of schizoaffective disorder and depression, exhibited wandering behaviors and frequently took items from snack carts and other residents. These behaviors were known to staff but were not communicated to the provider or addressed in the resident's care plan. Multiple staff members confirmed the resident's pattern of wandering and taking food, and the resident had previously attempted to leave the facility. Despite this, there was no evidence that the care plan was updated to address these behaviors or that interventions were implemented to mitigate the risks associated with them. On the evening of the incident, the resident with wandering behaviors took milk and belongings from the other resident, leading to a physical confrontation. Video footage confirmed that one resident made a fist and struck the other, who then retaliated by punching the first resident in the face, resulting in a visible bruise. The facility's policies required that care plans be updated as residents' conditions changed and that safety risks, including unsafe wandering, be addressed. However, these policies were not followed, contributing to the altercation and resulting injury.