Failure to Prevent Resident-to-Resident Abuse and Inadequate Behavioral Intervention
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, specifically when one resident with a history of aggressive behaviors struck another resident in the main lobby area. The resident who initiated the altercation had a documented history of dementia, moderately impaired cognition, and repeated episodes of verbal and physical aggression toward other residents, including name-calling, cursing, shoving, and hitting. Despite these ongoing incidents, the facility's interventions were limited to separating residents and redirecting them, without further evaluation or implementation of additional measures to prevent recurrence. Clinical record reviews and staff interviews revealed that the aggressive resident had multiple documented incidents of both verbal and physical aggression over several months, including shoving other residents, using offensive language, and physically striking or pushing others. Staff responses were generally limited to verbal reminders, redirection, or asking other residents to move, rather than addressing the root causes or modifying the care plan with more effective interventions. Incident reports were not consistently completed, especially when no physical injury was observed, and there was a lack of root cause analysis or a resident-centered approach to prevent further incidents. The facility's abuse prevention policy requires protection of residents from all forms of abuse, including resident-to-resident physical contact that results in harm, pain, or mental anguish. However, the facility did not adequately assess or address the ongoing behavioral issues of the aggressive resident, nor did it evaluate the effectiveness of existing interventions. Staff interviews indicated a general awareness of the resident's behaviors, but also a normalization of avoidance strategies rather than proactive prevention, leaving other residents vulnerable to further abuse.