Failure to Prevent Further Resident-to-Resident Abuse After Initial Incident
Penalty
Summary
The facility failed to initiate adequate protective actions to prevent further resident-to-resident abuse after an incident in which a resident with moderately impaired cognition and a history of wandering and behavioral symptoms entered another resident's room and struck both the resident and the resident's wife. The resident who committed the abuse had documented diagnoses including unspecified dementia and had previously exhibited wandering and physical behavioral symptoms directed towards others. Despite being placed on one-on-one observation following the incident, the resident continued to wander into other residents' rooms, creating ongoing potential for harm. Facility records and interviews revealed that the resident's care plan identified risks such as invading others' space and disruptions in common areas, but the interventions implemented did not prevent further opportunities for abuse. The facility's policy required removal of the accused resident from contact with others and supervision by staff until assessment and treatment options were determined. However, documentation showed that one-on-one observation was inconsistently provided, with the resident's wife at times assuming this role, and the resident continued to have access to other residents' rooms until eventual transfer to a behavioral health unit.