Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse and did not document progressive interventions for three residents who were identified as vulnerable due to severe cognitive impairment and dementia. Multiple incidents occurred in which one resident, who had a history of aggressive behavior related to dementia, physically assaulted other residents. These incidents included one resident placing her hands around another resident's neck, hitting another on the head, pushing down on a resident's chest, and slapping another resident. In each case, the residents involved were unable to provide statements due to their cognitive status, and staff intervened to separate the individuals and conduct assessments. The care plans for the residents involved did not include documentation of abuse or progressive interventions following these incidents. The aggressive resident's care plan noted the potential for aggression and included general interventions such as calm redirection, removal from situations, and 1:1 observation, but did not reflect updates or specific interventions after each incident. The facility's records show that the same resident was repeatedly placed on 1:1 observation and sent to the hospital after each event, but there was no evidence of care plan updates or additional measures to address the ongoing risk. Staff interviews confirmed that the aggressive behaviors were witnessed and responded to in the moment, but there was uncertainty about the duration and implementation of 1:1 observation and a lack of clarity regarding the facility's policy on managing such behaviors. The administrator acknowledged the absence of updated progressive interventions in the care plan and ongoing challenges with the resident's power of attorney, which impacted decision-making for further placement. The facility's abuse policy prohibits mistreatment and requires staff education, but the documented failures resulted in residents experiencing physical and emotional harm.