Failure to Protect Residents from Physical Abuse and Implement Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from physical abuse and did not ensure the implementation of care plan interventions for residents with known behavioral issues. In one incident, a resident with a history of psychotic behavior, verbal aggression, and intrusiveness became agitated during a group activity after another resident blew his nose nearby. The agitated resident expressed discomfort, stood up, and physically pushed the other resident back onto the couch, holding his arm down and verbally instructing him to stop. Staff did not intervene before the situation escalated, and the Rehabilitation Activity Leader left the two residents alone to seek help, during which time the altercation continued. The care plan for the resident with behavioral issues specifically required staff to intervene before agitation escalated, guide the resident away from the source of distress, and engage in calm conversation, but these interventions were not followed. Another incident involved a resident being physically assaulted by her roommate, who grabbed her breast and hit her in the face, resulting in a four-centimeter scratch on the left side of her face. The aggressor admitted to the action, expressing a delusional belief that the other resident had stolen her breast. The incident was discovered by a CNA, who observed the injury and blood on the resident's gown. The residents had no prior history of altercations, and both required varying levels of assistance with activities of daily living due to mental health diagnoses such as schizoaffective disorder and major depressive disorder. The facility's policy on abuse prevention and reporting prohibits any form of mistreatment, including abuse and neglect, and requires timely investigation and reporting of all allegations. Despite these policies, the facility failed to prevent physical altercations between residents and did not ensure staff followed established care plans and interventions designed to de-escalate potentially aggressive behaviors. These failures resulted in residents sustaining physical harm and not being protected from abuse as required.