Failure to Protect Residents from Abuse Due to Inadequate Behavioral Interventions and Supervision
Penalty
Summary
A resident with a history of major depressive disorder, major neurocognitive disorder due to Alzheimer's disease, and psychotic mood disorder was admitted to the facility and exhibited escalating aggressive and disruptive behaviors. Documentation shows that the resident became physically and verbally abusive towards staff and other residents, including making threats of physical harm, entering other residents' rooms, and taking their belongings. Despite repeated incidents of aggression, including physical assaults on staff and threats to other residents, the care plan was not updated in a timely manner to address these behaviors, and enhanced supervision or monitoring was not implemented. The facility failed to notify the interdisciplinary team (IDT) or provider of the resident's escalating behaviors and did not conduct behavior management evaluations or update interventions in response to the resident's aggression. There was also a lack of documentation regarding IDT meetings or behavioral management discussions, and the care plan was not revised to reflect new or worsening behaviors until after the resident was transferred to the hospital. Additionally, the facility did not report or investigate an allegation of resident-to-resident physical abuse, nor did it document provider notification or assessment following incidents of aggression and ineffective medication administration. Another resident was physically assaulted by the aggressive resident, resulting in tenderness to the jaw and the need for non-pharmacologic pain relief. The facility's own investigation confirmed physical contact occurred. The facility's policies required ongoing assessment, care planning, and monitoring for residents with behaviors that might lead to conflict or abuse, but these were not followed. The failure to implement timely interventions, update care plans, and notify appropriate staff and providers contributed to the deficiency in protecting residents from abuse.