Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in actual harm. One resident with severe cognitive impairment and a history of vascular dementia, depression, and a cerebrovascular accident was residing in the secured memory care unit and required assistance with activities of daily living, though she ambulated independently. Another resident, also in the secured memory care unit, had a history of dementia, aggressive behaviors, and was noted to have physical aggression towards others on multiple occasions. Despite documented incidents of aggression, there was no evidence that the physician was notified of these behaviors, and documentation of the specific behaviors was lacking. On the day of the incident, video review showed that the aggressive resident approached the other resident in the hallway, clapped his hands, and pushed her, causing her to fall. No staff were present in the hallway at the time. The injured resident was found on the floor by a nurse responding to a noise, and she was later diagnosed with nondisplaced fractures of the left superior and inferior pubic rami. Interviews and documentation revealed that the aggressive resident had a pattern of physical and verbal aggression, and staff were aware of these behaviors but did not consistently document them in nursing progress notes or notify the physician as required. The facility's policy required protections against abuse and mandated documentation and reporting of such incidents. However, the review found that staff primarily documented behaviors in the electronic record's task section and did not ensure that nurses followed up with appropriate documentation or physician notification. The lack of supervision in the hallway and insufficient behavioral documentation contributed to the failure to prevent the abusive incident, resulting in harm to the resident.