Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protection for residents with severe cognitive impairment and known behavioral issues, resulting in multiple incidents of resident-to-resident physical altercations. One resident with diagnoses including dementia, schizoaffective disorder, and a brain lesion, and who was on hospice services, exhibited wandering and aggressive behaviors. Despite these known risks, this resident was able to enter another resident's room and push that resident off the bed, as well as later push a roommate off the bed, causing both residents to fall to the floor. Clinical records and facility documentation revealed that the resident responsible for the altercations had a history of severe cognitive impairment, required supervision for transfers and ambulation, and had documented wandering and behavioral issues. The care plan directed staff to be present on the unit during the evening shift to redirect wandering behaviors, but the resident was still able to access other residents' rooms and physically interact with them. In one incident, the resident pushed a roommate off the bed, resulting in both residents being found on the floor and requiring hospital evaluation. The resident who initiated the altercation was found to have a subacute right subdural hematoma with subfalcine herniation following the incident. Interviews with facility leadership confirmed that the resident with behavioral issues had no roommate until after the first incident, and that the roommate was assigned despite available beds on other units. The facility was unable to explain how the roommate was protected from harm, given the known history of aggressive behavior. Facility policy prohibits abuse by anyone, including other residents, but the actions taken were insufficient to prevent further incidents of mistreatment.