Failure to Implement Effective Care Plan Interventions to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to develop and implement effective care plan interventions to protect residents' rights to be free from physical abuse, specifically in cases involving resident-to-resident altercations. Multiple residents with severe cognitive impairments and behavioral disturbances were involved in repeated incidents of physical and verbal aggression. One resident, with diagnoses including psychotic disorder, schizophrenia, and anxiety disorder, exhibited frequent physical and verbal aggression towards others, including hitting, kicking, pushing, and cursing, as documented in clinical records and staff observations. Despite these behaviors, the care plan interventions primarily focused on general reassurance, psychiatric consultation, and non-pharmacological approaches, but lacked specific, effective strategies to prevent physical aggression towards other residents. The documentation revealed that this resident repeatedly entered other residents' rooms, took their belongings, and engaged in aggressive acts such as hitting, slapping, and biting both staff and peers. Several incidents were recorded where this resident physically assaulted other residents, including sitting on another resident's leg, hitting a resident in the arm, and striking another on the shoulder. Staff interviews confirmed that the resident was difficult to redirect, medications were ineffective, and there was insufficient staffing to provide constant supervision. Staff expressed concerns about their ability to keep other residents safe from this individual's aggressive behaviors. Other residents involved in these altercations also had significant cognitive impairments and behavioral issues, as indicated by their assessments and care plans. The care plans for these residents generally included reassurance to decrease frustration but did not address the risk of physical altercations or provide interventions to prevent such incidents. Observations and interviews indicated that the facility's current interventions were inadequate to prevent resident-to-resident abuse, and staff acknowledged the limitations in their ability to supervise and manage the aggressive resident effectively.