Failure to Protect Resident from Physical Abuse Due to Lack of Behavior Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known history of aggressive behavior and dementia struck another resident in the face with a water pitcher, resulting in significant injuries. The injured resident sustained a facial contusion, lacerations to the upper lip and right eyebrow requiring stitches, and reported pain and emotional distress. Staff interviews and medical record reviews confirmed that the aggressor had previously exhibited aggressive behaviors, including yelling and striking at staff, and that these behaviors were known to the facility. Despite documented behavioral disturbances and medical provider notes recommending close monitoring and behavior tracking, the facility failed to implement consistent behavior monitoring for the resident with aggressive tendencies. Behavior monitoring was not initiated until after the incident, even though prior altercations and medical documentation indicated the need for such interventions. The Medication Administration Record (MAR) and care plans did not reflect daily behavior monitoring or tracking as ordered by the medical provider following earlier aggressive episodes. Staff and the Director of Nursing confirmed that behavior monitoring logs were not in place as required, and that the lack of monitoring prevented timely identification and intervention for escalating behaviors. The facility's policies required providing a safe environment and monitoring for aggressive behaviors, but these were not followed, directly contributing to the incident where one resident was physically abused by another.