Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect six out of seven sampled residents from abuse, including multiple incidents of physical abuse between residents. Several residents with severe cognitive impairment and dementia were involved in repeated altercations, including hitting, slapping, and other forms of physical aggression. Despite the facility's abuse policy stating that all residents should be free from abuse and that staff should monitor for signs and symptoms, staff were unable to prevent or adequately intervene in these incidents. In each case, the facility's investigations concluded that physical abuse was not substantiated due to lack of injury and the cognitive status of the assailants, but the surveyors determined that abuse did occur because the actions were willful, regardless of cognitive impairment. Multiple incidents involved a resident with a history of delusions, agitation, and physical aggression, who struck other residents on several occasions. This resident was known to wander, enter other residents' rooms, and become easily agitated, especially when she believed others were taking her belongings. Staff and care plans documented her behavioral issues and interventions such as redirection and increased supervision, but these measures were not sufficient to prevent repeated episodes of physical aggression. Other residents involved also had significant cognitive impairments and histories of behavioral disturbances, with some altercations occurring when residents entered each other's personal spaces or rooms. Staff interviews confirmed awareness of the behavioral challenges and the frequency of altercations, with staff acknowledging that supervision in common areas was insufficient at times. The facility's leadership expressed a belief that residents with dementia could not be willful in their actions, which influenced their interpretation of abuse incidents. However, the survey findings highlighted that the facility did not ensure adequate supervision, monitoring, or interventions to prevent abuse, resulting in multiple residents not being kept free from physical abuse by other residents.