Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from abuse by another resident, resulting in psychosocial harm and threats to safety. One resident, with a history of anxiety, depression, PTSD, and schizophrenia, reported being threatened and verbally abused by another resident who had a diagnosis of non-Alzheimer's dementia and schizophrenia. This resident was observed to have delusions and both physical and verbal behavioral symptoms directed toward others. Multiple incidents occurred, including one where the aggressive resident pushed another resident's wheelchair, leading to a physical altercation, and another where he pulled out a knife and threatened to kill two residents. Staff and other residents reported ongoing verbal abuse, threats, and aggressive behavior from this individual. Despite these repeated incidents, the facility's leadership, including the Administrator and DON, did not take sufficient action to prevent further abuse or to protect the affected residents. Documentation and interviews revealed that staff were aware of the aggressive resident's behaviors, but interventions were limited to redirection and enhanced supervision, which proved inadequate. There was a lack of consistent follow-up with the victims, and some staff and residents expressed that they did not feel safe. The aggressive resident continued to have access to other residents and was able to bring prohibited items, such as a knife and lighter, into common areas. The facility's failure to act promptly and effectively allowed the abusive behavior to continue, resulting in psychosocial harm to at least one resident and ongoing distress among others. Staff interviews indicated that the aggressive resident's behavior was a known issue, and some staff felt that the DON did not adequately address the situation. The Administrator and DON were not fully aware of all incidents, and there was a lack of communication and documentation regarding the threats and abuse. The situation escalated to the point where an Immediate Jeopardy was identified due to the risk of continued abuse and harm.