Failure to Protect Resident from Physical Abuse and Inadequate Post-Incident Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who was severely cognitively impaired, was sitting in the activities room when another resident, who had a documented history of aggression, hit the first resident on the right hand, resulting in visible redness. Witnesses, including another resident and an activities assistant, confirmed the incident, and a licensed vocational nurse assessed the injury. However, the medical record did not show evidence that the injured resident was monitored for 72 hours post-incident, as required by facility policy. The resident who committed the abuse had a care plan indicating the use of psychotropic medication for bipolar disorder with a history of verbal and physical aggression. Previous documentation showed this resident had been involved in another physical altercation with a different resident and had multiple episodes of aggression toward staff. Despite these incidents, the medical record lacked documentation of a change in condition, progress notes, or notification to the family and physician for the earlier aggressive episode. Interviews with staff, including CNAs, LVNs, and the DON, confirmed that the resident with a history of aggression was not consistently monitored or documented according to policy after incidents. Additionally, a recommended social services consultation for the aggressive resident was not documented as completed. The facility's failure to follow its own policies for monitoring, documentation, and intervention after abuse incidents contributed to the deficiency.