Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and intervention to prevent physical abuse between residents. Specifically, a cognitively impaired resident with a history of wandering entered another resident's room and bed, resulting in a physical altercation. The resident whose bed was entered attempted to remove the wandering resident, leading to the latter sustaining a bloody nose and developing a black eye. The incident was witnessed by a certified nurse aide (CNA), but the CNA did not report the event as required by facility policy. The resident who was injured had severe cognitive impairment, required substantial assistance with activities of daily living, and exhibited wandering behaviors. The resident was found the next morning with facial bruising and dried blood, which was only then reported to nursing staff. Medical evaluation confirmed facial contusions. The resident who attempted to remove the wandering resident also had severe cognitive impairment and a history of confusion, wandering, and occasional verbal altercations, but no prior physical aggression. Observations during the survey revealed that interventions intended to prevent recurrence, such as room changes and the use of stop signs to deter entry, were not effectively implemented. The rooms of the two residents remained adjacent, and no stop sign was present on the door as indicated in the facility's investigation. Additionally, staff failed to notice when other residents entered the same room and bed, indicating ongoing lapses in supervision and monitoring. Staff interviews confirmed that reporting protocols and monitoring practices were not consistently followed at the time of the incident.