Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent an incident of resident-to-resident abuse involving two residents. One resident, who had a history of suspected abuse or neglect and cognitive impairment, was subjected to a racially derogatory term and was spat on by another resident while walking in the hallway. The incident was reported by the affected resident to nursing staff, and a witness confirmed hearing the altercation and intervened by instructing the aggressor to return to his room. The aggressor, who had diagnoses including delusional disorder, schizophrenia, and unspecified psychosis, was known to have a history of spitting on other residents and using offensive language toward both residents and staff. Despite these known behaviors, the care plan for the aggressor did not include updated interventions following the incidents of spitting and verbal abuse. The care plan interventions remained unchanged even after multiple documented behavioral incidents, and there were no new strategies implemented to address the ongoing risk. The facility's policies affirm the right of residents to be free from abuse and to be treated with respect and dignity, but these were not upheld in this case, as evidenced by the lack of timely and appropriate updates to the care plan and interventions for the resident exhibiting abusive behaviors.