Failure to Prevent Resident-to-Resident Altercations and Inappropriate Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and inappropriate behaviors, as evidenced by multiple incidents involving residents with cognitive impairments and behavioral symptoms. One resident with severe cognitive impairment and a history of physical behavioral symptoms was observed striking another resident in the hallway after a verbal altercation. The care plan for this resident included interventions such as moving the resident to a calm environment and maintaining distance from others, as well as 15-minute checks, but the incident still occurred, indicating a lapse in supervision and implementation of interventions. Another resident with moderate cognitive impairment was involved in two separate incidents of inappropriate sexual contact with female residents. In one case, the resident was observed groping a female resident's breast while watching television, and in another, the same resident was seen rubbing another female resident's thigh in the dining room, despite her attempts to push his hand away. The care plan for this resident directed staff to prevent sexual contact with a specific resident but did not include interventions to prevent similar behavior with other residents. Staff and resident interviews confirmed that these incidents were witnessed and reported by both staff and other residents. The facility's policies on managing inappropriate resident behavior and sexual relationships for cognitively impaired residents were reviewed. The policy on resident-to-resident aggression directed immediate intervention and separation but did not specify further preventive measures. The policy on sexual relationships defined cognitive impairment and outlined the need to protect residents unable to provide consent, but the care plans and supervision in practice were insufficient to prevent repeated incidents. These deficiencies demonstrate a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents and inappropriate behaviors.