Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, resulting in physical harm. One resident with severe cognitive impairment and a history of aggressive behaviors repeatedly entered other residents' rooms and engaged in altercations. Despite documented incidents of aggression, including punching another resident in the head and mouth, the facility only implemented temporary 1:1 supervision, which was discontinued due to staffing limitations. The resident was then placed on 15-minute checks, but continued to display aggressive and wandering behaviors, with staff frequently needing to intervene to prevent escalation. Following the initial incident, the aggressive resident continued to exhibit disruptive behaviors, including entering other residents' rooms and causing distress among both residents and staff. Progress notes indicated that staff found it difficult to manage the resident's behaviors and ensure the safety of others, especially when the resident was not on 1:1 supervision. Despite ongoing behavioral issues and staff concerns, the facility did not maintain the higher level of supervision that had proven effective in preventing further incidents. A subsequent altercation occurred when the same resident entered another resident's room and struck them multiple times with a cane, resulting in serious injuries including a traumatic brain injury, subdural hematoma, and subarachnoid hemorrhage. The injured resident required hospitalization and follow-up with neurosurgery. Interviews with staff and documentation revealed that the facility was aware of the escalating behaviors but did not consistently implement or sustain interventions necessary to prevent resident-to-resident abuse, leading to immediate jeopardy for resident safety.
Removal Plan
- Educate licensed nurses and direct care staff on member to member altercation, abuse education, and managing behaviors.
- Social worker will review members for appropriate placement.
- Educate all staff on member to member altercation policy, member behavior policy, care planning policy, mood assessment, and root cause analysis.
- Social worker and clinical staff will review progress notes for residents exhibiting aggressive behaviors or patterns of escalating behaviors and update care plans accordingly.
- Interdisciplinary team will review policy for member behaviors.
- Staff to review care plan for members exhibiting behaviors for appropriate interventions.
- Provide education to all staff regarding elopement on their first shift in their work unit.
- Provide education on managing aggressive behaviors and providing intervention before there is member to member contact (early detection of escalating behavior) on their first shift in their work unit.
- Provide education to social services on responding to residents' psychosocial needs, behaviors and wishes to be discharged, developing a plan and updating the care plans.
- Provide education to managers on completing a root cause analysis for falls, elopements, and escalated behaviors.
- Social worker to audit progress notes for any residents with increased behaviors. Care plan and interventions to be updated based on audit findings. Findings to be presented to quality assurance and performance improvement committee for review and suggestions. Findings discussed at interdisciplinary team clinical daily stand-up meeting.