Failure to Prevent Resident-to-Resident Abuse and Inadequate Response to Wandering Behaviors
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by two separate incidents involving resident-to-resident interactions. In the first incident, a cognitively intact resident with congestive heart failure and chronic obstructive pulmonary disease reported that another resident, who had a history of wandering and cognitive impairment, entered their room at night and touched their leg. Although the incident was reported and a room change was offered, there was no documented evidence that an individualized care plan was developed or implemented to prevent further potential abuse from the wandering resident. In the second incident, a resident with mild cognitive impairment and left-sided weakness sustained an elbow injury while attempting to remove the same wandering resident from their room at night. The injured resident reported fear and began closing their door at night to prevent further intrusions. Documentation showed that the wandering resident had a known history of entering other residents' rooms and required frequent redirection, but interventions such as one-to-one supervision and 30-minute monitoring had been discontinued. Staff interviews confirmed that no effective or consistent interventions were in place to address the wandering behavior or to protect other residents from potential harm. Despite multiple staff and family reports of ongoing wandering and disruptive behavior by the cognitively impaired resident, facility leadership and clinical staff were either unaware of specific incidents or did not implement adequate measures to address the risks. The facility's policies required investigation and intervention for abuse and resident-to-resident altercations, but there was a lack of evidence that these policies were followed or that sufficient steps were taken to ensure resident safety in these cases.