Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, including physical and verbal altercations between residents, as well as neglect in monitoring and documenting aggressive behaviors. Several incidents occurred between two residents with histories of cognitive impairment and behavioral disturbances, resulting in repeated episodes of yelling, hitting, grabbing, and pushing. Despite known histories of aggression and trauma, staff interventions were limited to separating the residents and placing them on periodic checks, which proved ineffective in preventing further altercations. Documentation of these incidents was inconsistent, with some episodes not recorded in the electronic medical record. One resident, with diagnoses of bipolar disorder, depression, and dementia, exhibited severe cognitive impairment and a pattern of aggressive behavior towards others. This resident was frequently observed wandering unsupervised in the facility, despite care plans indicating a risk for aggression. Another resident, with dementia and anxiety, reported fear and distress following these altercations, leading to self-isolation and avoidance of common areas. Staff interviews revealed uncertainty and lack of recent training in managing aggressive behaviors, and the facility's leadership acknowledged gaps in staff education and training compliance. Additional deficiencies were noted in the facility's response to a resident who returned intoxicated from a community outing and physically assaulted his roommate. Although the care plan required one-to-one observation when the resident was intoxicated, there was no documentation that this intervention was implemented. Behavioral tracking sheets also failed to record aggressive incidents as required. These failures resulted in multiple residents being subjected to abuse and neglect, contrary to facility policy and regulatory requirements.