Failure to Prevent and Respond to Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving aggressive resident-to-resident interactions and inappropriate staff conduct. One resident with severe cognitive impairment and a history of schizophrenia, schizoaffective disorder, and dementia exhibited repeated aggressive behaviors, including striking another resident with a pencil, causing puncture wounds and slight bleeding, and later hitting the same resident over the head with a metal object. Documentation and interviews confirmed that these incidents resulted in physical injury and fear for the affected resident, who expressed feeling unsafe and requested to press charges. Another incident involved the same aggressive resident slapping a different resident on the back, which was observed by staff and caused distress, though no physical injury was noted. Despite the known behavioral risks and documented history of aggression, the facility did not consistently implement or document 1:1 monitoring for the aggressive resident, even after multiple incidents. Staff interviews revealed confusion and lack of clarity regarding the duration and documentation of 1:1 supervision, and some staff were unaware of the full extent of the resident's aggressive behaviors. The facility's behavioral documentation system was not fully integrated into the official reporting process, leading to gaps in communication and awareness among nursing and administrative staff. Additionally, the facility's abuse prevention policy required immediate separation, assessment, and monitoring following resident-to-resident incidents, but these procedures were not reliably followed or documented. Further, a nurse was reported to have made an inappropriate and demeaning comment to a resident while pushing them in a wheelchair, stating it hurt her back and she would need a forklift to move the resident. This comment was not in line with the facility's abuse prohibition policy and contributed to a failure to ensure residents were free from mental abuse. The cumulative failures in monitoring, reporting, and staff conduct placed residents at risk for continued abuse, injury, and psychosocial harm.