Failure to Prevent Resident-to-Resident Abuse Due to Lack of Behavior Care Planning
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving resident-to-resident altercations. One resident with a known history of wandering and dementia entered another resident's room, leading to a physical altercation where the second resident became agitated, grabbed the wandering resident, and both ended up on the floor. The wandering resident kicked the other in self-defense. Despite the known behavioral history and high risk for elopement, there was no behavior care plan in place for the wandering resident prior to the incident. Another incident involved the same wandering resident being observed holding their roommate by the collar in the doorway of their room. This resident had a documented history of previous altercations, yet no behavior care plan had been initiated to address or mitigate these risks. Staff interviews confirmed that the resident was known to wander and could become physically aggressive if not handled appropriately, but interventions to prevent such incidents were not documented or implemented before the altercations occurred. Additionally, a third resident, who was at risk for abuse due to immobility and cognitive impairment, was involved in a physical altercation with the wandering resident, resulting in scratches and visible injuries. The facility's own policies required thorough investigation and care plan updates for residents at risk of victimization or with aggressive behaviors, but these were not in place prior to the incidents. Documentation gaps were also noted, such as missing nursing progress notes regarding the altercation and lack of behavior care planning for the involved residents.