Failure to Protect Resident from Abuse Due to Inadequate Mental Health Intervention
Penalty
Summary
The facility failed to protect a resident from abuse when it did not adequately evaluate or address the effectiveness of interventions for another resident's mental health and substance use needs. One resident, with a history of substance abuse and recent methamphetamine use, exhibited escalating behavioral disturbances, including vandalism, aggression toward staff, and ultimately a physical assault on another resident. Despite multiple incidents indicating a change in mental status and behavior, including reports of auditory hallucinations, aggression, and erratic actions, the facility's documentation lacked evidence of reassessment or adjustment of care plan interventions to address these acute mental health concerns. The resident who committed the assault had a documented history of substance abuse and mental health diagnoses, including adjustment disorder and alcohol abuse. In the days leading up to the incident, this resident was observed engaging in disruptive and violent behaviors, such as letting air out of vehicle tires, scratching cars, and attempting to physically harm staff. The resident was also noted to have refused medications and was found to be under the influence of methamphetamines, as confirmed by hospital records. Despite these warning signs and hospital visits for psychiatric evaluation, the facility did not implement or document enhanced monitoring or effective interventions to mitigate the risk posed by this resident. The victim of the assault was a cognitively impaired resident with a history of traumatic brain injury and required supervision for daily activities. This resident was physically pushed over in his wheelchair by the other resident, who then attempted to further harm him before staff intervened. The victim expressed ongoing fear and emotional distress following the incident. The facility's records did not show consistent documentation of safety checks or targeted interventions for either resident in response to the escalating behaviors and the eventual assault.