Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from abuse, resulting in physical and sexual harm to two residents. One resident with a history of mood disorder, anxiety, alcohol-induced dementia, and psychosis was known to be verbally and physically aggressive, often refusing care and exhibiting behavioral disturbances. Despite these ongoing behaviors and documented refusal to allow others into his room, there was no evidence that interventions were implemented to prevent other residents from entering his room. This lack of intervention led to an incident where another resident, who had cognitive communication deficits, dementia, and a tendency to wander, entered the aggressive resident's room and sustained multiple injuries, including skin tears, bruising, and a fractured coccyx, after being assaulted. Additionally, another resident with a history of wandering and confusion entered the room of a resident without cognitive impairment and engaged in inappropriate sexual contact. The affected resident reported the incident, expressing agitation and anxiety, and requested medication for anxiety. Documentation showed that there were no interventions implemented to increase monitoring of the resident with wandering behaviors to prevent such incidents. The report highlights that the facility did not follow its own abuse prevention and resident-to-resident altercation policies, which required monitoring for aggressive behaviors and implementing care plan changes to prevent further incidents. The failure to provide adequate supervision and interventions for residents with known behavioral issues directly resulted in physical and sexual abuse, causing actual harm to at least one resident.