Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Ineffective Interventions
Penalty
Summary
A resident with a history of dementia, behavioral disturbances, and wandering behaviors repeatedly entered other residents' rooms, including that of another resident who was cognitively intact but had a history of behavioral and physical aggression. The care plan for the resident with dementia identified risks for wandering, impaired safety awareness, and lack of personal boundaries, with interventions such as redirection and offering diversions. Despite these interventions, documentation shows that the resident continued to wander, enter other residents' rooms, and exhibit exit-seeking behaviors. Staff notes indicated that the resident was not effectively redirected and that interventions to address aggressive behavior were not always documented or effective. On the day of the incident, there were no planned activities on the unit, and staff struggled to keep the resident with dementia occupied. Multiple staff interviews confirmed that the resident was in and out of rooms, taking items, and that other residents were becoming agitated by these intrusions. Staff attempted to redirect the resident with various activities, but these efforts were short-lived and did not prevent further wandering. The resident ultimately entered the room of another resident, resulting in a physical altercation where the cognitively intact resident sustained a bruise and skin tear to the face, as well as significant pain and distress. Interviews with staff and the affected resident revealed that the resident with dementia had been entering the same room multiple times over several days, and the affected resident had repeatedly reported this to staff without effective resolution. Staff acknowledged that 15-minute checks were routine and not a significant new intervention, and that the lack of activities and high resident acuity made supervision difficult. The facility's policy required identification, assessment, and intervention for residents at risk of conflict, but documentation and staff actions did not demonstrate effective implementation of these measures, resulting in physical and psychosocial harm to the resident who was assaulted.