Failure to Protect Residents from Physical Abuse and Inadequate Incident Response
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving multiple incidents where one resident with dementia and Alzheimer's disease physically assaulted other residents. The resident in question exhibited repeated aggressive behaviors, including slapping, hitting, and using objects to strike other residents, all of whom had varying degrees of cognitive impairment. Incident reports documented several episodes where this resident slapped or hit others, sometimes causing visible injuries such as a knot on the head or facial soreness. Despite these occurrences, there was no evidence that staff provided education following the incidents, nor were law enforcement or the residents' families consistently notified as required by policy. Care plans for the involved residents were not consistently updated to reflect the incidents or to implement new interventions to prevent further abuse. For example, after a resident was slapped and sustained a head injury, their care plan was not revised to address the new risk. Similarly, other residents who were assaulted did not have their care plans updated to include additional safety measures or interventions. Staff interviews revealed a lack of awareness and documentation regarding post-incident education, law enforcement notification, and the completion of safe surveys to assess and ensure resident safety after each event. The facility's own policy required screening, training, prevention, identification, investigation, protection, and reporting of abuse, but these steps were not followed in practice. Staff and administration admitted to not contacting law enforcement for incidents they deemed minor, such as slapping, and did not conduct safe surveys or provide education after the altercations. There was also no evidence of quality assurance reviews or new interventions being established following the incidents. The repeated failure to follow established protocols and update care plans left residents vulnerable to further abuse.
Removal Plan
- Resident #28 has been referred for inpatient geri-psych services.
- Resident #28 was immediately placed on one-on-one supervision until departure from the facility.
- All staff will receive inservice training regarding abuse prevention including resident to resident abuse.
- Staff will receive training to intervene when resident to resident abuse occurs, report abuse immediately to the Administrator, assess or evaluate the resident who sustained abuse for injury, and document those findings in the resident record.
- An intervention(s) will be established for each episode of resident-to-resident abuse at the time of the occurrence, communicated to staff, and updated to the resident's care plan.
- An intervention communication form will be used to communicate to staff all new occurrences and interventions.
- All staff received inservice either in person or by phone call. For any staff member that could not receive inservice in person or by phone, they will be required to receive inservice before their next scheduled shift.
- Inservice education will be provided by the DON, RN, and Care Plan Coordinator.
- Resident #28 had no access to any other resident outside of the memory care unit.
- All residents on the memory care unit were safe from abuse immediately when one on one supervision was established for resident #28.
- Resident #28 was transferred via EMSA from the building for geri-psych services.
- Each resident on the memory care unit will receive a head to toe assessment for injury and will be asked about their safety.
- The Plan of Removal will be completed.