Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent resident-to-resident abuse, resulting in a resident with dementia and severe cognitive impairment being pushed by another resident with a history of paranoid schizophrenia, delusions, hallucinations, and aggression. The incident occurred when the cognitively impaired resident, who had a documented history of wandering and entering other residents' rooms, was found on the floor outside the aggressive resident's room after being pushed. The injured resident sustained a closed left femoral neck fracture, requiring surgical intervention and a subsequent decline in functional status, now needing assistance with activities of daily living and ambulation. Prior to the incident, the resident with dementia was known to wander independently throughout the facility and had been documented as entering or lingering near other residents' rooms on multiple occasions. The care plan for this resident included interventions for wandering and cognitive impairment, but these primarily focused on redirection, encouragement to attend activities, and non-pharmacological interventions. Staff interviews revealed that the resident required frequent reminders not to enter other residents' rooms due to her memory deficits, and that she did not regularly participate in group activities, preferring to spend time alone. The resident who pushed the other had a well-documented history of delusions, paranoia, and aggressive behaviors, including previous incidents of threatening staff, refusing care, and expressing fears of being harmed or poisoned. Staff and behavioral logs indicated that this resident had exhibited threatening and unpredictable behavior on several occasions, and some staff reported feeling unsafe when providing care. Despite these known risks, there was no evidence of enhanced supervision or specific interventions to prevent resident-to-resident altercations between these two individuals prior to the incident.