Failure to Protect Residents from Physical Abuse Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to protect residents on the behavioral health unit (BHU) from physical abuse and did not provide adequate supervision or timely interventions for a resident with escalating aggressive behaviors. After a resident with schizoaffective disorder and bipolar type stopped consistently taking her prescribed antipsychotic medication, Zyprexa, there was no written plan of care developed to monitor or prevent potential inappropriate and aggressive behaviors resulting from the medication refusal. Despite a documented increase in behavioral manifestations such as screaming, yelling, anger outbursts, and refusal of care, the facility did not initiate individualized interventions or update the care plan to address these changes. The resident subsequently engaged in multiple incidents of physical aggression, including slapping another resident in the face, making threatening gestures, and throwing a lunch tray at her roommate. These incidents were witnessed by staff and reported by the affected residents, who expressed fear and a lack of safety. Staff interviews confirmed that the resident's behavior had become unpredictable and aggressive, and that other residents were afraid. Despite these events, the facility did not promptly implement increased supervision, such as 1:1 monitoring, or revise the care plan to address the ongoing risk to other residents. Facility policies required immediate safety measures, individualized care planning, and prompt reporting and intervention in cases of resident-to-resident altercations or behavioral escalations. However, the interdisciplinary team did not convene to address the resident's change in condition, and the care plan remained generic and insufficiently tailored to the resident's needs. The lack of timely and appropriate interventions resulted in continued aggressive incidents, leaving other residents exposed to harm and feeling unsafe.
Removal Plan
- Resident 1 was placed on 1:1 supervision and moved to an individual room.
- Resident 1's care plan was revised to address her aggressive behavior and her needs of supervision.
- Director of Staff Development (DSD) started all staff in-services on abuse prevention, mandatory reporting, and immediate interventions during altercations.
- DON/designee started rounds and interviews in BHU to ensure no other residents were at immediate risk.
- Resident 1's care plan was revised and included 1:1 supervision, alerted triggers, and de-escalation protocol.
- Resident 1's 1:1 supervision and utilization of the individual room will continue until IDT, attending physician, and/or psychiatrist determined Resident 1 was stabilized.
- IDT reviewed risks including room safety and potential for further resident - resident abuse.
- Root cause analysis conducted to determine why supervision and interventions were delayed.
- Implementation of weekly behavioral risk rounds.
- Implementation of de-escalation protocol included: CNAs to immediately inform LN when a change of condition occurs related to mood, behavior, aggression or psychiatric decompensation including medication refusal, the LN escalates the report to the on-duty Supervisor, and the Supervisor communicates to Manager, Social Services, DON, and ADM.
- To ensure timely implementation of interventions, the attending physician and/or psychiatrist will be notified simultaneously.
- Interventions to prevent further harm to others were implemented to prioritize resident safety.
- Care plans were reviewed and revised to address Resident 1's current conditions, behavioral triggers, and new interventions.
- The IDT to ensure care plans were individualized to each resident's needs.
- To prevent the recurrence of abuse, immediate safety action and long-term care plan modifications are expected after all incidents.
- Collaborating with the DON, the Mental Health Case Manager/Provider and Social Services will oversee the BHU.