Failure to Protect Residents from Physical Abuse During Behavioral Incident
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when an agitated resident, with a documented history of behavioral disturbances and aggression, was left unattended in a shared room with two other residents. The agitated resident was observed swinging two metal wheelchair footrests in the air, exhibiting aggressive behavior. A certified nurse assistant (CNA) attempted to verbally redirect the resident and remove the footrests but was unsuccessful and left the room to seek assistance, leaving the agitated resident alone with the other two residents, both of whom had significant cognitive and physical impairments. While the CNA was away, the agitated resident struck one of the roommates multiple times in the head with the metal footrests, causing severe facial lacerations, bruising, and pain. The injured resident, who was bedbound and unable to defend herself, required emergency medical attention and was transferred to an acute care hospital for evaluation and treatment of her injuries, which included a forehead hematoma, periorbital laceration, and a possible nasal bone fracture. The other roommate, also bedbound, witnessed the attack and expressed fear for her life. Interviews and record reviews revealed that staff were aware of the aggressive resident's behavioral history, including prior incidents of agitation and aggression, and that care plans specified the need for staff intervention to protect others. However, staff failed to implement appropriate interventions to ensure the safety of the roommates during the incident. The facility's policies on abuse prevention and resident safety did not provide specific guidance for managing an agitated resident in possession of a dangerous object, and staff did not utilize available methods such as overhead paging to request immediate assistance, resulting in a failure to prevent harm.