Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse for two residents in the memory care unit. One resident, with diagnoses including dementia and cognitive communication deficit, was assessed as having severely impaired cognition and a history of verbal behavioral symptoms. Another resident, also with severe cognitive impairment and additional psychiatric diagnoses, was identified as having potential for physical behaviors and poor impulse control. An incident occurred in which the second resident slapped the first resident on the face, as reported by a CNA who heard the slap and was informed by another resident. The CNA confirmed that the resident admitted to slapping the other after being told to 'shut up.' Interviews with staff revealed that the incident was not directly witnessed by staff, but was reported by a resident and confirmed by the CNA through resident admission. The affected resident was unable to recall or confirm the incident due to cognitive impairment. Staff interviews indicated that the resident who committed the act had a history of verbal outbursts but had not previously been observed to hit others. The facility's policy required staff to identify, correct, and intervene in situations of possible abuse or neglect, and to provide ongoing education on abuse prevention and reporting. Despite these policies, the facility did not effectively prevent the incident of resident-to-resident abuse. The event was not immediately observed by staff, and the response relied on secondhand reports and post-incident interviews. The facility's failure to ensure adequate supervision and implementation of abuse prevention policies resulted in a resident being physically struck by another resident, with the incident only coming to light after the fact through indirect observation and resident statements.