Failure to Provide Psychosocial Support After Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to provide medically related social services to support a resident's psychosocial well-being after the resident witnessed and was threatened during a violent incident involving another resident. The incident occurred when a resident with severe cognitive impairment and behavioral disturbances became agitated, removed metal wheelchair footrests, and began swinging them aggressively in a shared room. Staff attempted to intervene but were unable to de-escalate the situation before the agitated resident struck another bedbound roommate, causing visible injuries. During this event, another resident in the room, who was also bedbound and had a diagnosis of anxiety disorder and moderate cognitive impairment, was directly threatened and feared for her safety. Following the incident, the resident who witnessed and was threatened by the aggressive behavior reported experiencing fear, anxiety, and emotional distress. Despite these clear signs of psychosocial trauma, no nursing or facility staff checked on or followed up with this resident after the event. Interviews with staff confirmed that they were unaware of the resident's emotional state and had not assessed her for trauma or distress. The Director of Nursing and the Registered Nurse involved both acknowledged that the resident should have been assessed for psychosocial well-being and that the Social Services Designee should have been notified to provide support. A review of facility policy indicated that staff are responsible for identifying and addressing factors negatively affecting residents' psychosocial functioning, including resident-to-resident altercations and behavioral problems. The policy also states that social services staff are responsible for providing or arranging for mental and psychosocial counseling services as needed. In this case, the facility did not follow its own policy, resulting in a failure to provide necessary social services to a resident who experienced significant emotional distress after a violent incident.