Failure to Protect Residents from Physical Abuse and Inadequate Response to Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in one resident sustaining a hand injury and extensive bruising. Resident S, who had early-onset Alzheimer's and severe dementia, was non-verbal and frequently wandered throughout the memory care unit, including into Resident U's room. Resident U, who had a known history of physically aggressive behaviors, engaged in multiple physical altercations with Resident S, including hitting, kicking, and punching. Despite these incidents, there were no interventions implemented to prevent Resident S from entering Resident U's room, nor were there any changes made to either resident's care plans to address the ongoing altercations. Staff and family members witnessed several of these altercations, and staff expressed concerns for Resident S's safety. Documentation revealed that Resident S suffered a skin tear on her hand and multiple bruises on her legs as a result of these encounters. However, there was a lack of thorough assessment and documentation regarding the extent of Resident S's injuries, and no investigation was conducted to determine the cause of the bruising or to prevent further harm. Additionally, staff interviews indicated that management was aware of Resident U's behavioral history prior to admission, but no preventive measures were put in place. The facility's policy required immediate assessment and investigation of abuse allegations, as well as the implementation of interventions to ensure resident safety. Despite this, the interdisciplinary team did not assess the situation or recommend interventions following the altercations. The administrator and social services designee were not fully informed of the incidents or injuries, and there was no evidence of a plan to protect Resident S or other residents from further abuse by Resident U.