Failure to Prevent Resident-to-Resident Abuse and Neglect Due to Unsecured Hazardous Equipment
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. One resident, a female with Alzheimer's disease, intermittent explosive disorder, psychotic disorder with delusions, and major depressive disorder, reported that a male resident threatened to cut off her foot with a hand saw and then used the saw to cut a groove into her walker. This incident was corroborated by direct observation of the damaged walker and by interviews with staff and the male resident, who admitted to both threatening the female resident and using the saw on her walker. The female resident expressed fear and distress following the incident, and her family member confirmed that she was upset and scared when recounting the event. The male resident involved had diagnoses including Parkinson's disease, unspecified dementia, major depressive disorder, anxiety disorder, muscle wasting, and muscle weakness. He was noted to have a history of being resistive to care and potentially physically and verbally aggressive due to cognitive impairment. On the day of the incident, he was able to obtain a hand saw from an unlocked maintenance closet, which he then used in the presence of other residents and staff. Staff interviews confirmed that the saw was taken from him after he was seen with it, and that he had accessed it from the maintenance office, which was not secured at the time. The facility's failure to keep hazardous equipment, such as the hand saw, secured and inaccessible to residents directly led to the incident. Staff interviews indicated that while they were trained to recognize and report abuse and neglect, the maintenance office was left unlocked, allowing the male resident to access the saw. The incident was reported to facility administration after the fact, and the female resident was left feeling unsafe and distressed as a result of the threat and the damage to her mobility aid.