Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving four residents with cognitive impairments and behavioral disturbances. In one incident, a resident with severe cognitive impairment and a history of aggression became agitated when another resident approached the dining table. The agitated resident grabbed the other resident's hand and slammed it onto the table. Staff present intervened by calmly asking the aggressive resident to release the hand, which was done, and the incident was reported to the charge nurse. The care plan for the aggressive resident included interventions to move the resident to a calm area when agitated, but on this occasion, the resident was taken to the dining room, which was noted by staff as a noisy environment not suitable for calming the resident. Another incident involved a resident with cognitive impairment and behavioral disturbances striking another resident on the hand when the latter approached the table. Both residents involved had care plans addressing their behavioral issues, including interventions for aggression and wandering. The incident was documented in the facility's incident report, and staff were aware of the behavioral risks associated with these residents. The facility's Abuse Prevention Program policy affirms residents' rights to be free from abuse and outlines procedures for removing residents who allegedly abuse others from contact during investigations. However, in these cases, the facility did not effectively implement interventions or environmental controls to prevent resident-to-resident physical abuse, despite documented behavioral risks and care plan interventions for the residents involved.