Failure to Prevent Resident-to-Resident Abuse and Emotional Distress
Penalty
Summary
The facility failed to prevent both physical and emotional abuse among residents, specifically involving two residents who were subject to abuse by another resident with a known history of behavioral issues. One resident, who had diagnoses including schizophrenia, alcohol abuse, and major depressive disorder, had a care plan in place due to a history of striking out at staff and peers. Despite this, staff did not follow the planned interventions, such as removing the resident from situations at the first signs of agitation and providing a safe space. This failure led to an incident where the resident physically assaulted another resident, resulting in extensive bruising to multiple areas of her body, including her forearm, elbow, breast, palm, wrist, fingers, and shoulders. The assaulted resident, who had a history of PTSD and other psychiatric diagnoses, experienced significant emotional trauma, including fear, crying, shaking, and symptoms that triggered her PTSD. Following the initial physical altercation, the same resident verbally abused and threatened another resident, causing her to experience mental anguish and fear. This resident, who was cognitively intact but had physical disabilities, reported feeling unsafe, kept a grabber stick under her pillow for protection, and expressed distrust in the facility. Staff interviews confirmed that the resident who committed the abuse had a pattern of angry outbursts and altercations, and that staff were aware of his behavioral history. However, one-to-one supervision and other preventative interventions were not implemented until after the second incident of abuse occurred. Documentation and communication lapses were also evident. The DON was not informed of the full extent of the altercations or the interventions that were (or were not) implemented. The executive director was aware of the incidents but could not produce documentation of one-to-one supervision. Staff interviews revealed concerns about the resident's behavior and the adequacy of supervision, but these concerns were not acted upon in a timely manner. The facility's own abuse policy required supervision and intervention for residents with behavioral needs, but these measures were not effectively carried out, resulting in physical harm and emotional distress to two residents.